OR Today - April 2017 by MD Publishing

CE ARTICLE SURGICAL ROBOTS PAGE 40

SPOTLIGHT ON

NUTRITION

KATE LOCKE PAGE 60

TAKE GOOD CARE NURSES • SURGICAL TECHS • NURSE MANAGERS

RETRAIN CRAVINGS PAGE 72

APRIL 2017

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SHIFT CHANGE OR Staffing Shortage

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OR TODAY | April 2017

CORPORATE PROFILE: D. A. SURGICAL D. A. Surgical founder R. Dan Allen has been passionate about patient positioning for almost 40 years. He is the retired founder of Allen Medical Systems as well as the inventor of the Allen Stirrup, TrenGuard Trendelenburg Patient Restraint and many other solutions to contemporary patient positioning problems. He came out of retirement to start D. A. Surgical after he saw robotic-assisted surgery generate a need for new patient positioning devices.

SHIFT CHANGE OR Staffing Shortage BY DON SADLER

SHIFT CHANGE: OR STAFFING SHORTAGE The impending nurse shortage is real and will impact the OR and surgery centers in coming years. About two-thirds of perioperative nurse leaders today are over 50 years old and one-fifth are over 60. Also, 37 percent of OR nurses say they plan to retire within the next three years and 65 percent plan to retire by 2022.

SPOTLIGHT ON: KATE LOCKE More than a decade ago, Kate Locke first believed that she might be cut out for pediatric nursing. Locke was interviewing for a position at the Children’s Hospital of Philadelphia, and saw a young patient attached to a feeding pump, but that didn’t stop him from romping past with his Little Tikes pushcar, happy as could be. She has been hooked ever since.

OR Today (Vol. 17, Issue #03) April 2017 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 302691530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530. For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. © 2017

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April 2017 | OR TODAY

CONTENTS

departments

PUBLISHER

John M. Krieg | john@mdpublishing.com

VICE PRESIDENT

Kristin Leavoy | kristin@mdpublishing.com

32 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 16 20 22 24

News & Notes AAAHC Update AORN Conference ASCA Update Company Showcase: Cygnus Medical

Taylor Martin Cindy Galindo Adam Pickney

CIRCULATION Lisa Cover Laura Mullen

IN THE OR 28 31 32 40

Suite Talk Market Analysis Product Showroom CE Article

OUT OF THE OR 66 Fitness 68 Health 72 Nutrition 74 Recipe 80 Pinboard

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INDUSTRY INSIGHTS NEWS & NOTES

STAFF REPORT

Censis Technologies Signs Supplier Agreement with HealthTrust Censis Technologies has executed a supplier agreement with HealthTrust in the newly established surgical instrument management software category. Effective March 1, 2017, the contract encompasses CensiTrac subscription and customized professional services and support. In 2002, Censis Technologies launched CensiTrac; the first surgical instrument tracking system in the industry capable of tracking to the instrument-level. CensiTrac has become a web-based software system offering electronic count sheets, instrument and tray management, and paperless record keeping. By offering CensiTrac in a SaaS (Software as a Service) based model, customers receive enhancements throughout the year enabling them to stay up-to-date in a continuously evolving technological and regulatory environment. “We are thrilled to be a part of the surgical asset management solutions in this new category,” Censis CEO Randy Smith said. “It’s an honor to be able to offer our software to HealthTrust’s acute care and sub-acute facilities.”

Advanced Cooling Therapy Receives CE Mark Approval Advanced Cooling Therapy (ACT) has received CE mark approval for use of their Esophageal Cooling Device (ECD) with the Altrix Precision Temperature Management System by Stryker. ACT’s technology platform provides a novel method to control patient temperature using the esophageal environment. The ECD is designed to modulate and control patient temperature when clinically indicated through a single use, fully enclosed triple lumen system that is inserted into the esophagus. Two lumens attach to existing temperature modulation equipment while a third lumen simultaneously allows gastric decompression and drainage. The ECD can be rapidly inserted by most trained health care professionals, in similar fashion to a standard gastric tube, and can be used to control patient temperature in the operating room, recovery room, emergency room or ICU. No other products on the market are approved to use the esophageal environment for whole-body temperature modulation. “This new CE mark clearance addresses a significant need in a growing market, in which temperature management is increasingly important for both warming and cooling patients when clinically indicated,“ commented Markus Tödtling, International Sales Manager for ACT. “The ECD’s compatibility with a new line of control units, or heat exchangers, now available on the market, enables us to meet the growing needs of hospitals across Europe that are utilizing the Altrix Precision Temperature Management System in emergency departments, intensive care units, and operating rooms for a wide range of cooling and warming needs.” Robin Drassler, Vice President of Sales, North America, notes that FDA clearance for the ECD compatible with the Altrix Precision Temperature Management System is still pending, but says “Because our existing product line is compatible with the majority of existing control units, the ECD is already being deployed in a growing number of hospitals worldwide.” The ECD received FDA de novo clearance in June of 2015 for use with the Medi-Therm III by Stryker and received FDA 510(k) clearance in January 2016 for use with the Blanketrol II and III Hyper-Hypothermia systems made by Cincinnati Sub-Zero, a Gentherm Company. It received its CE Mark in Europe in 2014, with an expanded indication for use up to 120 hours in 2016, and is licensed for sale in Canada and Australia. WWW.ORTODAY.COM

April 2017 | OR TODAY

INDUSTRY INSIGHTS NEWS & NOTES

ASP Launches Next-Generation Sterilization System Advanced Sterilization Products (ASP), part of the Johnson & Johnson Medical Devices Companies, has announced that the new STERRAD 100NX System with ALLClear Technology is available in the United States and to select customers in Europe, Middle East and Africa (EMEA). Recently cleared by the U.S. Food and Drug Administration, the next-generation system is designed to help Central Sterile Services Departments maximize efficiency and comply with government and facility requirements. The STERRAD 100NX System with ALLClear Technology is a low-temperature sterilization system that uses proprietary algorithms to minimize workflow interruptions and cycle cancellations. The system includes features that simplify system operation and automatically monitors conditions, providing pre-sterilization cycle load conditioning, load checks and system checks to reduce operator error while improving productivity. Additionally, it can be paired with ASP ACCESS to automate data sharing across all connected ASP systems and hospital networks, minimizing the need for manual documentation. Systems are currently in use at a select number of hospitals in the United States and Europe. It will be rolled out in Australia, New Zealand, Canada, Latin America and Japan, as well as additional markets in EMEA and Asia Pacific, throughout 2017.

Diversey Care Launches Oxivir 1 Disinfectant Cleaner Wipes Sealed Air’s Diversey Care division has launched Oxivir1 readyto-use disinfectant wipes to its infection prevention portfolio. Oxivir 1, powered by Accelerated Hydrogen Peroxide (AHP), is effective against bacteria, enveloped and non-enveloped viruses, TB and fungi in one minute or less. With disinfectant claims on 75 key pathogens, it now leads Diversey Care’s lineup of fast, effective, responsible and sustainable disinfectant wipe solutions. Like other members of the Oxivir family, Oxivir 1 has the 12

OR TODAY | April 2017

best possible safety rating (category IV) on the market. The one-step solution, designed for use in health care environments, is tough enough to clean and disinfect surfaces and equipment in one pass while being gentle on staff and surfaces. It is non-irritating to skin and eyes, requires no personal protective equipment and is compatible with most common health care surfaces and equipment. The wipes are available in a variety of sizes. The 11”x12” wipes are ideal for larger area cleaning and disinfection in

operating rooms, emergency departments and patient rooms. “The new Oxivir 1 wipes raise the bar by reducing turnover time while keeping costs in line,” said Carolyn Cooke, Vice President Healthcare North America, Diversey Care. “Health care staff can increase speed and effectiveness with this powerful one-step disinfectant cleaner, which is effective against a broad spectrum of pathogens in just one minute. The wipes improve compliance by staying wet on surfaces for the required label contact time, which ensures disinfection while streamlining the process.” WWW.ORTODAY.COM

NEWS & NOTES

Healthmark Offers Pop-Up Tray Corners Healthmark Industries has announced the addition of the Pop-Up Corner Card to its sterilization packaging product line. Designed to protect wrapped trays from punctures or tears caused by sharp corners or feet, the 4x4x2 inch Pop-Up Corner Card simply pops up for easy assembly and fits most trays or baskets. Manufactured from a white rigid paper carton, the Pop-Up Corner Card is heat resistant up to 275˚ F.

Existing reprocessing techniques prove insufficient for flexible endoscopes Current techniques used to clean endoscopes for reuse are not consistently effective, according to a study published in the February issue of the American Journal of Infection Control, the official journal of the Association for Professionals in Infection Control and Epidemiology (APIC). The findings of this study support the need for careful visual inspection and cleaning verification tests to ensure that all endoscopes are free of damage and debris before they are high-level disinfected or sterilized and used on another patient. Currently, flexible endoscopes, including gastrointestinal, urological, and respiratory endoscopes, are reused following cleaning and highlevel disinfection. However, results from the new study conducted by Ofstead & Associates Inc., suggest that even more rigorous reprocessing techniques of endoscopes are not consistently effective, and organic residues often remain. “Understanding issues with the effectiveness of reprocessing techniques is critically important as WWW.ORTODAY.COM

institutions seek to improve the quality of endoscope cleaning and disinfection,” said lead study author Cori L. Ofstead, MSPH, Ofstead & Associates Inc. “Even though top-notch methods were used, the endoscopes in this study had visible signs of damage and debris, and tests showed a high proportion were still contaminated.” Using a longitudinal study design, Cori L. Ofstead, et al. performed three assessments of 20 endoscopes over a seven-month period. The assessments involved visual inspections with a tiny camera, microbial cultures, and biochemical tests to detect protein and adenosine triphosphate (ATP) – a marker that identifies organic matter. These assessments were used to identify endoscopes that required further cleaning and maintenance. During the final assessment, the researchers found that all 20 endoscopes examined had visual irregularities, such as fluid, discoloration and debris in channels. Furthermore, samples from 12 of

20 reprocessed endoscopes (60 percent) had microbial growth, indicating a failure of the disinfection process. Of note, endoscopes reprocessed using current recommended guidelines and those that were cleaned at least twice before high-level disinfection exhibited similar culture results. Further results indicated that about 20 percent of endoscopes in each group exceeded post-cleaning benchmarks for ATP and protein residue. Moreover, ATP levels were higher for gastroscopes, which are used for upper GI procedures, than the endoscopes used for colonoscopy. “The finding of residual fluid in 95 percent of endoscopes tested was significant because moisture fosters microbial growth and the development of biofilm – which can be difficult or impossible to remove,” said Ofstead. “This confirms the importance of cleaning, disinfecting, and drying to ensure patient safety.” Visit www.apic.org for resources on reprocessing reusable medical devices. April 2017 | OR TODAY

INDUSTRY INSIGHTS NEWS & NOTES

Free Online Courses Highlight Informed Consent Process Physician-patient communication and patient empowerment can help patients make more effective informed choices for their care. To improve the informed consent process, the Agency for Healthcare Research and Quality (AHRQ) engaged The Joint Commission and Abt Associates to provide guidance through free online courses for hospital leadership and other health care professionals. Informed consent is an area that some hospitals are struggling to comply with. In 2016, Joint Commission surveyors identified compliance issues related to informed consent in more than 500 hospitals. The on-demand courses consist of two modules. The Leadership Module reviews each topic that an informed consent policy should address and provides examples from a fictional hospital of what each part of the policy could look like. The module also outlines strategies and system changes for hospitals to create a culture that supports a high-quality policy of informed consent and illustrates how to

launch an informed consent quality improvement initiative. The course provides downloadable worksheets and 34 resources. The Healthcare Providers Module provides strategies and tools to improve the informed consent process through effective communication and patient engagement. The concept of informed consent as a team process and tips on adequate documentation are also presented. Each module offers 2 continuing education (CE) credits and includes interactive features such as video recordings, illustrative scenarios, model conversations, patient stories, and a pre-test and post-test. Joint Commission accredited health care organizations may register for the courses through The Joint Commission’s online learning management system (LMS). An implementation guide and other resources are available on the AHRQ website. Hospitals that do not participate in The Joint Commission’s LMS may obtain the courses for their own LMS from AHRQ by emailing healthliteracy@AHRQ.gov

Estape TrenMAX Offers Alternative to Foam-Based Positioning Pads The Estape TrenMAX from Innovative Medical Products is a new positioning system that provides surgeons and OR staff an alternative to foam-based solutions when positioning patients for Trendelenburg or Reverse Trendelenburg gynecological surgeries such as hysterectomies and abdominal myomectomies. TrenMAX boasts more than twice the standard coefficient of friction compared to memoryfoam positioners. It provides a secure positioning system possible for patient movement control in today’s market. This means patient movement no longer has to be expected as a “normal” occurrence that regularly comes 14

OR TODAY | April 2017

with Trendelenburg or Reverse Trendelenburg positioning, or when tilting the OR table and patient. All of these orientations can be safely carried out during the same surgical procedure, if necessary, without having the surgeon or staff take time to reposition the patient or the robot because of patient movement. The key component of the TrenMAX system is IMP’s proprietary Sticky Pad. The Sticky Pad adheres directly to the patient’s torso and fastens securely to the OR table’s side rails to prevent the patient from moving or sliding off the OR table. For maximum, secure fixation of the base pad to the OR table, TrenMAX em-

ploys patent-pending TrenMAX clamps that tightly secure the base pad’s hook-and-loop material straps fastened to the OR table’s side rails. In addition to its holding power, TrenMAX provides an arm strap system that allows access to leads and IVs by anesthesiologists, as well as preventing potential neurological impairment, per AORN recommendations, caused by sheet tucking; and there is not a requirement for a chest strap, improving ventilation. Also, the system doesn’t use shoulder bolsters preventing potential nerve damage by eliminating pressure on the brachial plexus caused by shoulder-holder devices. WWW.ORTODAY.COM

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INDUSTRY INSIGHTS AAAHC UPDATE

BY RAYMOND GRUNDMAN, MSN, MPA, FNP-BC, CASC

AAAHC UPDATE HOW TO DEVELOP AN ORIENTATION PROGRAM FOR YOUR SURVEY TEAM: BUILDING SHARED UNDERSTANDING

very organization has a distinct culture, but cultural norms may be subtle and are inherently unstated. When a survey team arrives on-site to review your facility, it’s to your advantage to help them understand who you are as an organization. A formal orientation program is an opportunity to get the survey off to a good start. For the surveyor (or survey team), an orientation establishes a level of familiarity that increases speed to productivity. It introduces those who will serve as resources for information and improves the accuracy and efficiency of data collection. This means the team has more time to share best practices in their role as consultative educators. It also means that the final survey report will be an authentic reflection of the organization and of the hard work that has gone into preparing and maintaining readiness for an accreditation survey. Conversely, an orientation benefits the organization’s staff by presenting the survey team as important (but welcome) visitors. The language of accreditation can seem foreign to new employees – or employees new to the accreditation process. Meeting and interacting with the survey team early on can improve the ability to understand what the surveyors are looking for and how to provide it, and can position them as mentors there to help raise the bar on safety and quality. 16

OR TODAY | April 2017

PART 1: A WELCOME

Orientation can be a moveable feast that takes place at multiple locations within a surgery center. AAAHC asks its applicant organizations to make a private or semi-private space available for the surveyors to review documents, conduct interviews, and confer with one another during their time on-site. You can make your surveyors feel welcome by showing them to this space and having any documentation (policy and procedure manuals, or access to electronic resources) that was previously requested available there. PART 2: ESTABLISHING A CONTEXT

Think of orientation as the process of introducing your organizational culture. Your surveyors are familiar with ambulatory surgery centers, but they are not familiar with your ambulatory surgery center. Start with the environmental attributes: your location, the population you serve, and any local health risks associated with these.

Then place your facility within this environment: your expertise/ what you’re known for, special procedures, unique equipment, universal characteristics of your staff (CNOR, CAPA, ACLS, PALS). The survey team should receive an overview of the company’s mission and operating structure, including how the center fits into the rest of a larger company (if appropriate). A template for creating this context would include: • History of legal entity (date and type) • Mission, vision, values • Ownership • Physical description (number of ORs, procedure rooms, PACU beds, etc.) • Floor plan • Significant relationships (managment company, bank/financing, legal, insurer, etc.) PART 3: YOUR PEOPLE MAKE THE DIFFERENCE

Provide an overview of who provides oversight. Describe your governance structure and name your leadership. Identify committees and their responsibilities. For example: Quality Improvement Committee monitors and recommends actions for: Transfers\Admissions Infections Delays and Cancellations Pharmacy Issues Patient Care Policies WWW.ORTODAY.COM

AAAHC UPDATE

Credentials & Privileges Medical Records\Peer Review QA/PI Studies Occurrence, Adverse Incident Reports While much of your orientation presentation may take place in a conference room, it is also useful to have the survey team tour the facility to meet staff in their immediate work area. In a smaller ASC, it is helpful for them to meet all the employees since small businesses often require close collaboration among all workers. List changes that have occurred since the last survey; new policies and/or procedures, new services, new providers added. PART 4: OPERATIONAL UPDATE

Provide a picture of your year from an operational perspective. • Case volume and clinical statis-

tics (infections, transfers, patient and provider satisfaction) • Specialty mix • Payer mix Include a high-level summary of your financial data and describe any initiatives at cost savings and/or revenue enhancement (which, by the way, are perfect topics for QI studies). List facility improvements and equipment or technology upgrades. CLOSE WITH A LOOK FORWARD

Your survey team will be interested in what you are planning or considering for the future. They may have resources to offer and certainly you want credit for the full range of your activities including marketing efforts and accreditation preparation. With everyone on the same page, the survey is ready to begin. We

understand that every organization is nervous when surveyors arrive. Hopefully your presentation to the survey team has also reminded your staff of the hard work and dedication that is seen in your center every day. Ray Grundman is Chief External Relations and Business Development Officer at AAAHC and is also an active surveyor. With over 35 years’ experience in ambulatory health care including managed care, group medical practice, surgery centers and college health. He has seen the accreditation process from multiple perspectives. He is a frequent speaker at professional conferences on topics ranging from the administration of an ambulatory surgery center to the most frequent deficiencies found by AAAHC surveyors across a variety of settings – and how to avoid them.

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INDUSTRY INSIGHTS AORN CONFERENCE

READY TO HARNESS THE POWER OF YOU?

START PLANNING FOR AORN’S GLOBAL SURGICAL CONFERENCE & EXPO

erioperative nurses tackle a number of physical, mental, and emotional challenges in their daily practice to advocate for their patients and ensure optimal outcomes.

“Taking time out to network with colleagues, update education and explore new OR technologies is an important part of advancing your practice,” says Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, AORN director of Evidence-Based Perioperative Practice. Spruce notes that the theme of the 2017 Global Surgical Conference & Expo this April 1–5 in Boston is “Power of You.” She highlights several ways that perioperative nurses who attend the conference can build their network, understand new evidence-based practice recommendations and strengthen their individual practice knowledge. GROW YOUR NETWORK

A strong professional network can support a nurse in staying ahead of changing practice demands and continually advancing career trajectory. AORN has arranged several different 20

OR TODAY | April 2017

approaches for nurses to network at the conference. For example, a number of social and education events are designed to give attendees chances to connect with other attendees based on similar practice specialties and professional goals. Social networking events include: the First-Time Attendee Orientation, AORN Foundation Silent Auction and Boston T-Party, as well as fitness and yoga classes. Two education summits at the conference will bring together experts on specific practice topics. These include: • Global Summit – a one-day event bringing together international perioperative experts to discuss the issues impacting perioperative health care around the world. • Executive Leadership Summit – a two-day event for perioperative leaders to gain new insights and strategies for improving practice compliance, leveraging big data, building a high-performing team, and more. For attendees who would rather engage in more informal networking events, a new way to get colleague input on a pressing practice issue is through Online Collaboration Boards where attendees can post a tough problem or clinical question that peers and colleagues can then provide suggestions or

success stories about. “Surgical Attire” and “Wound Classification” are two of the collaboration board topics for 2017. POWER YOUR PRACTICE

Five days of break-out education sessions, and other independent learning options provide continuing education credits on important practice topics broken down by key education tracks. These tracks include: • Ambulatory • Clinical • Education • Evidence-Based Practice/Research • Infection Control/Infection Prevention • Informatics • Leadership/Management • Professional Development • Quality • Risk Management • Simulation Implementation support for new guidelines released by AORN, including the new guideline on Surgical Smoke Safety, will be discussed and new perspectives on challenging practice issues such as preventing surgical site infections will be addressed. Spruce encourages attendees to make time for attending these sessions to better understand the evidence supporting the guidelines, which can be an important “conversation-starter” as WWW.ORTODAY.COM

Learning new skills, techniques, and processes is easier with simulation training and AORN has added four new simulation trainings to the floor as part of the 2017 conference. (Phototography by AORN)

new practices based on this evidence are implemented in collaboration with frontline nurses. For those working toward the new Certified Surgical Services Manager certification, specific education opportunities for these nurses is also outlined in the schedule, providing a strong opportunity to gain a number of continuing education credits required for this certification through the conference. Independent learning opportunities will also be offered through an Education Conference Hub where recorded sessions will be streamed, and more than 300 posters will be presented in person and through an online gallery covering new research, evidence-based practice, and clinical improvements and innovations. The exhibit hall, perioperative nursing’s largest surgical products tradeshow floor, will provide stayand-listen workshops and take-home study guides that offer continuing education. Additionally, exhibitors will provide a hands-on learning opportunity to learn about the latest OR technologies, giving attendees a chance to spend more meaningful time with manufacturers who can share insights on optimal use for these technologies. And, this conversation goes both ways, giving attendees opportunities to share concerns WWW.ORTODAY.COM

and suggestions with OR technology representatives. RECHARGE YOUR PASSION

Each day of the conference a general session speaker will provide unique tools for helping perioperative nurses to remember the power within and get the skills to hold on to it through tough workplace challenges. The sessions will give attendees a chance to gain new perspectives and possibly renew their passion for the nursing profession with insights from these speakers: • Brad Montgomery – A guru on the topic of happiness and personal power for good in the workplace, Montgomery will open the conference with his insights on the science of happiness and the individual power each person has to be happy and spread happiness around them to instill positivity in the workplace. • General (Retired) Anne Dunwoody – As the nation’s first female 4-star general, Dunwoody will share her no-nonsense tactics for achieving professional success and being the kind of leader people want to follow and look up to. • Marshall Goldsmith – Recognized as THE executive leadership coach, Goldsmith will share the

simple questions a person can ask themselves to be better every day, while being more aware of the triggers that can derail a perioperative nurse from personal and professional success. KNOW WHAT YOU NEED FROM THE CONFERENCE

The trick with making the most of the AORN conference experience is being able to take what you’ve learned, share it with colleagues, and incorporate it into practice. This is something AORN conference planners take into account when planning the conference, largely because they know first hand how important it is to share the evidence and energy from the conference with colleagues, Spruce notes. She suggests that nurses preparing to attend the conference start looking at their education deficits, identifying their wants for evidence to improve practices, and also connect with colleagues to plan networking opportunities at the conference. For More Information, visit aorn.org/ surgical expo or read AORN’s Conference Blog (www.aorn.org/surgicalexpo/conference-blog ) to get in-depth insight on the conference from those who are planning and presenting. April 2017 | OR TODAY

INDUSTRY INSIGHTS ASCA UPDATE

BY WILLIAM PRENTICE, ASCA CHIEF EXECUTIVE OFFICER

AN ASC WISH LIST

ith a new administration in the White House, a new secretary at the U.S. Department of Health and Human Services and health care front and center in the Congressional debate, one thing is certain – more change is on the horizon.

With change comes opportunity, so at ASCA, we’ve put together a short ASC Wish List for the new Administration. Number one on that list is to put an ASC payment policy in place that ensures that ASCs’ annual Medicare payment updates equal the Medicare payment updates hospital outpatient departments (HOPD) receive each year. This is not a new request, but it is a critical one. As we have said before, ASC payment updates that are based on the Consumer Price Index for All Urban Consumers (CPI-U), as ASC updates are today, do not reflect the rising costs of health care. The hospital market basket used to determine HOPD payment updates today more accurately reflects the increasing costs that ASCs are encountering as they work to continue to provide the high quality care they have always been known for. Payment updates that would stop the growing divergence between ASC and HOPD payment rates would go a long way toward ensuring that Medicare beneficiaries have continued access to the top-quality, lower cost care that ASCs provide. In his first days in office, President Donald Trump has clearly established his intention to reduce some of the federal administra22

OR TODAY | April 2017

tive and regulatory burdens that have been imposed on health care providers and others over time. In keeping with that idea, we propose that the Centers for Medicare & Medicaid Services (CMS) do away with the ASC approved procedures list. Instead, Medicare should simply reimburse ASCs for all of the procedures that it reimburses HOPDs for providing.

Members of Congress from both sides of the aisle support the ASC model of care and the steady progress ASCs are making toward further improvements in outpatient surgical care. Producing and maintaining a separate list of approved procedures for ASCs adds a layer of bureaucracy to the Medicare program that is simply unnecessary given the quality and safety records associated with ASCs and the other quality assurance systems already in place. In fact, ASCs are already performing many procedures that are not on Medicare’s approved pro-

cedures list for their privately insured and self-paying patients and achieving outstanding outcomes for those patients. The approved procedures list does little more than prevent Medicare beneficiaries from gaining access to that same care in the more affordable, higher value ASC setting. During his presidential campaign, in his inaugural speech and since he has been in office, one of the most consistent messages President Trump has sent is his deep-seated support for U.S. businesses. As small businesses that employ local residents, pay taxes and support development and activities in their communities, ASCs are the embodiment of many of the goals this administration has put forth in that area. At the same time, ASCs offer extensive benefits to patients, physicians and the future of outpatient surgery that are entirely disconnected from the political landscape. We ask that this new administration back the policies that help ASCs survive and thrive, and we stand ready to work with President Trump and his team whenever possible to help define those policies. To make certain that President Trump and his staff and advisers are fully aware of the cost savings that ASCs can provide, we point to two important studies conducted in recent years. The first, conducted by researchers at the University of California-Berkeley, shows that ASCs save Medicare and its beneficiaries $2.3 billion per year. The second was conducted by national health care quality and cost data provider Healthcare Bluebook in partnership with the nation’s largest independent WWW.ORTODAY.COM

ASCA UPDATE

administrator of health plans for selffunded employers HealthSmart. That study shows that ASCs currently save commercial and employer-sponsored plans and their beneficiaries more than $38 billion per year. In both cases, the studies revealed ASCs have ample capacity to do more. Cutting the cost of health care while maintaining the quality of that care and offering expanded choice and access to care is not a partisan issue. Members of Congress from both sides of the aisle support the ASC model of care and the steady prog-

ress ASCs are making toward further improvements in outpatient surgical care. Our Wish List includes the hope that this administration will capitalize on the broad-based support ASCs enjoy and encourage policies, like price transparency and systems that support informed consumers, that will encourage more procedures to move into the ASC setting. As the conversations in Washington, D.C., that will determine the future of the U.S. health care marketplace continue, we invite all members of the ASC community to join ASCA

at our annual meeting, ASCA 2017, this year in Washington, D.C., May 3-6. We are inviting all of our meeting participants to join us in visits to Capitol Hill where we will be meeting with members of Congress and advocating for the policies ASCs need in place to be able to continue to offer both Medicare and non-Medicare patients the high-value outpatient surgical services ASCs provide. William Prentice is the chief executive officer of the Ambulatory Surgery Center Association.

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INDUSTRY INSIGHTS COMPANY SHOWCASE

STAFF REPORT

COMPANY SHOWCASE

CYGNUS MEDICAL

ygnus Medical™ provides innovative medical products and services. A leader in the industry, Cygnus Medical does more than listen to customers. The company develops unique, industry-first solutions to specific problems found in hospitals and healthcare facilities. An early example of Cygnus Medical’s dedication to its customer base was the creation of the first-ever immediate bedside cleaning kit for endoscopes.

The First Step Bedside Kit

Prior to the introduction of the First Step™ Kit, the bedside cleaning of flexible endoscopes was a cumbersome step that was often skipped. Although society standards and manufacturers’ instructions for use required bedside cleaning, properly preparing the detergent and dispensing it uniformly was difficult. The First Step Bedside Kit simplified the endoscope cleaning process by providing the supplies needed to prevent bioburden from drying and solidifying in the endoscope’s 24

OR TODAY | April 2017

channels. Today, industry compliance has dramatically elevated, and bedside endoscope cleaning is recognized as an essential step in the cleaning process. First Step Kits are available in Ready-to-Use and Add Water Kits. Ready-to-Use Kits offer convenience of use, which increases staff compliance and turnover time. The ready-to-use detergent ensures a properly mixed formula every time. The combined effect is 100% compliance, 100% of the time. The 500 ml Add Water Kit offers ease of storage and a reduction in shipping costs because water is added at the point of use. The Kits are 100 percent compliant with SGNA and manufacturers’ guidelines, safe for use on all flexible endoscopes, and available with a variety of cleaning pad options, including the popular Draco Microfiber Deep-Cleaning Pad. First Step Pouches are also user-friendly and space-efficient. All First Step Kits ensure the proper dilution of enzymatic detergent, and are available in 100 ml, 200 ml and 500 ml sizes. All Kits contain Simple2™ Multi-Tiered Enzymatic Detergent and an endoscopic cleaning pad.

Simple2 effectively dissolves blood, fat, tissue, protein and other forms of organic material. Simple2 is lowfoaming, non-toxic, non-corrosive, latex-free, neutral pH and safe to use on all flexible endoscopes.

The Oasis™ Scope Transport Tray

As the market transitioned into single-use options for transporting soiled endoscopes, most options offered little to no support or protection for the scope. As a rigid disposable option, the Oasis™ Scope Transport Tray was the first disposable tray suitable for clean and soiled instruments. Lapses in the cleaning of reusable endoscope transport trays can lead to cross-contamination in the surgical work area. The Oasis Scope Transport Tray offers an economical single-use alternative that protects patients and staff from contamination and infection. Bedside cleaning is performed within the Oasis Tray, keeping residual run-off contained. This creates a cleaner work environment and reduces the risk of hospitalacquired infections. Oasis Trays are WWW.ORTODAY.COM

CYGNUS MEDICAL

latex-free and are made of a biodegradable plant-based material. This is a 100 percent renewable resource reducing the facility’s carbon footprint. The Tray’s rigid construction protects and contains endoscopes during transport and is large enough to safely hold an endoscope without damaging it. The Oasis Tray’s color-coded reversible lid clearly differentiates clean (green) and soiled (red/ orange) scopes. They are space efficient, stackable and nestable. Also, the trays meet SGNA recommendations for transporting soiled scopes in a closed container to prevent the spread of infection.

SingleCycle™ Disposable Instrument Tray

Instruments leaving a clinic need to be properly contained in a closed container with a biohazard label. Red containers holding clean instruments and unmarked containers are leading to Health Department and Joint Commission citations. Expanding on the concept of the Oasis Tray’s rigid single-use containment for clean and soiled instruments, Cygnus Medical recently released the steam sterilization compatible SingleCycle™ Disposable Instrument Tray. Made of a biodegradable renewable resource, SingleCycle Trays are perfect for instruments traveling to and from clinics. WWW.ORTODAY.COM

The Dragontail™ Channel Brush

Healthcare studies and data continue to show the limitations and ineffectiveness of manual cleaning products for flexible endoscopes. Cygnus Medical has taken the amazing properties of microfiber, and adapted it for use in cleaning difficult to reach endoscope channels. The patented Dragontail™ cleaning element is constructed of multiple lint-free Draco™ microfiber strands that are able to capture particles at a 4 micron level as it passes through the endoscope’s channel. Unlike bristles or silicone discs, which glide over adhered contamination, the microfiber cleaning element detaches, captures and removes gross contamination. In a comparative study, under identical conditions, the Dragontail™ Channel Brush cleaned 468 times more contamination than a traditional style channel brush.

The Tray Belts™

For years many companies sold corner guards as a solution for preventing rips in their sterile wrap. Corner Guards are placed on the tray corners beneath the CSR wrap. This may offer some protection, but unfortunately tray corners are rarely the main cause of damage to the sterile wrapping. In

some cases the corner guards within the wrapping, may actually contribute to moisture collection problems, like wet packs, that can compromise sterile wrapping during steam sterilization. The Tray Belts™ solution began as a simple concept … if you put on knee pads to protect your pants from being ripped, would you wear them inside your pants or outside? From this concept the Tray Belts™ Sterile Wrap Protection product was born. Tray Belts offer more complete protection than corner guards. Tray Belts are applied to the exterior of the wrapped tray. They cushion and protect the sterile wrap completely. They protect wrapped trays from the external damage that can occur during sterilization, storage and transport. The Belts also prevent abrasion marks and damage caused by dragging the wrapped tray. Since Tray Belts are applied to the exterior of the sterile wrapping they don’t collect moisture, like corner guards. When it comes to economics, Tray Belts are the clear winner over corner guards. The amount of Tray Belts™ material needed to protect a tray is relative to the tray size. For large trays, whether you are using Tray Belts or corner guards, the cost is about equal, but if you are using Tray Belts, small and medium trays cost less per tray to protect. This isn’t the case with corner guards, four corner guards are needed regardless of tray size. Large or small, there is no reduction in cost, the price to protect a tray with corner guards is fixed. Tray Belts are compatible with steam sterilization. Tray Belts are also available in BeeSafe™ Honeycomb material which is compatible for use in low-temperature sterilizers. These are just a few of the innovative products Cygnus Medical offers its healthcare customers. For more information about these products and several others, visit cygnusmedical.com. April 2017 | OR TODAY

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IN THE OR SUITE TALK

STAFF REPORT

SUITE TALK

Conversations from the OR Nation’s Listserv

ANTIBIOTIC STOP TIMES At some facilities it is required to document antibiotic start and stop times in order to receive payment. Does this include the OR? Is the OR exempt from this rule? A: We document both times. A: We document start times only.

time it completed the infusion for pre-surgical abx. Often this is confused with the requirement to discontinue the abx after surgery within 24 hours.

A: You are required to document the start time (i.e. within 60 minutes of incision). You are A: We document our abx not required to document the start time. However, it is

an NDNQI indicator that at our facility is reviewed by Press Ganey, so I assume that it is part of the credentials for payment. A: We just document the start time.

MUSIC IN THE OR Does your facility allow music in the OR? Who gets to pick the music? What are the pros and cons of playing music during a procedure? A: We have music in the OR. A: Every facility is different. At The team takes turns picking. my current employer, music A pro is that I think it helps is very prevalent. It’s a “group with patient anxiety. A con decision” many days as is sometimes the music can to what type. Most often mask other important sounds. someone uses their phone to

stream Pandora or the like. In my previous life, we had docking stations and staff/ physicians would use their phones to play their individual playlists.

RE-GOWNING When a surgeon forgets to put on lead is it appropriate to let him back out of a gown go put on lead and come back into the same gown? Why do they think this is OK? A: No.

A: If the surgeon hasn’t A: The best practice is to put his hands in past the re-gown. A: No it is not OK. Isn’t the elbow of the gown it is scrub person using their time probably OK. The best opmore wisely than holding a tion is to get a new gown. gown for a forgetful surgeon? 28

OR TODAY | April 2017

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SUITE TALK

CLEANING PRODUCTS IN THE OR SUITE

We have recently revised our contact isolation policy for the operating room which calls for stripping linens and disinfecting the patient cart/bed in the OR Suite after transfer to OR table. The cart is then returned to the common hallway for new linens to be applied. A question was raised whether it is acceptable to use disinfectant wipes (we use CaviWipes) in the OR suite if the case is already “open?” The only information I could find in 2017 AORN Guidelines pertains to aerosol use – which we already know is not allowed. I appreciate any insight or references anyone may have. A: I’m not sure that “cleaning” or movement of linens should be completed in an “open” OR suite in any manner. Movement of the linens may cause changes in air flow and use of wipes in the suite could cause airborne contamination of sterile fields. A: T hat is a great revision to an isolation policy. I do not think there would be

an issue with doing this in the room. The product is wet which will trap any organisms that may be on the object. The only concern, and this is a stretch, is the additional movement in the OR while the patient is in there and the sterile field is open. Limited movement is a tool for decreasing risk for infection.

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 MARKET ANALYSIS

STAFF REPORT

TEMPERATURE MANAGEMENT MARKET STAYS HOT

emperature management solutions are used to maintain a normal body temperature for patients during surgical procedures.

Patient warming and cooling devices offer several benefits such as reducing loss of blood during surgeries, lowering the risks of neurological disorders post cardiac arrests, rapid recovery after surgeries, and decreasing risks of SSIs. These benefits in turn can reduce a patient’s stay at a hospital and therefore lower health care costs. Another benefit is a significantly lower rate of readmissions. The patient temperature management market is expected to see continued growth over the next five years, according to a ReportLinker summary of the Inkwood Research report “Global Patient Temperature Management Market By Enduser Forecast 2016-2022.” “The patient temperature management market was valued at $1.97 billion in 2015 and is expected to reach $3.19 billion by 2022, growing at a CAGR (compound annual growth rate) of 7.1 percent during the forecast period 2016-2022,” according to ReportLinker. “The patient warming systems market accounted for a large share and is expected to witness the highest growth during the forecast period of 2016-2022.” The market for the temperature management market is driven, in part, by a rapid rise in the number of health WWW.ORTODAY.COM

care organizations adopting temperature management systems in multiple clinical applications and settings for the benefits of patients, according to the release. “With emerging health organizations and hospitals implementing patient warming devices, enormous market growth can be predicted,” according to ReportLinker. “Some of the other reasons for the growth of patient temperature management market are rise in incidences of nervous system and cardiovascular disorders, technological enhancements, development of mobile devices, enhanced health care infrastructure and conferences or symposiums on patient temperature management.”

“ The patient temperature management market was valued at $1.97 billion in 2015 and is expected to reach $3.19 billion by 2022...” “The patient temperature management market can be categorized on the basis of application areas such as acute care, newborn care, perioperative care, and others,” according to ReportLinker. “The rise in number of health care organizations setting up standards or guidelines for the use of temperature management systems in maintaining normothemia during neurological and cardiac surgeries is likely to accelerate the growth of the market.” ReportLinker states that North America accounted for the largest share

of the market in 2015 and is expected to remain the leader in the near future. “This dominance can be attributed to a large number of surgical procedures that are taking place in the region,” PR Newswire adds. “Europe has the second largest share of market due to the development of new products.” Another report also predicts growth in the temperature management market. The global patient temperature management market is anticipated to reach a value of $4.5 billion by 2025, according to a report by Grand View Research Inc. “With rising need for warming and cooling therapies, major companies are also focusing on improving the products through technological advancements aimed at serving the growing complications related to perioperative surgeries,” according to Grand View Research Inc. “For instance, Cincinnati (Sub-Zero) introduced Kool-Kit with Blanketrol III, which is used as a patient cooling system. These surface cooling blankets and pads have evolved as innovative temperature management products that provide temperature management at surgical sites, while maintaining the desired body temperature. Surface cooling systems help maintain patients’ normal body temperature by circulating cold fluid or air through blankets or surface pads that are wrapped around them. Moreover, blood and fluid temperature management that work by circulating warm or cold saline in a patient’s body through a catheter inserted into the central nervous system have also evolved in recent times.” April 2017 | OR TODAY

IN THE OR PRODUCT FOCUS

3M BAIR HUGGER The new 3M Bair Hugger multi-position upper body warming blanket fulfills the need to optimize patient body surface coverage for a variety of surgical procedures and adapts to accommodate a wide range of challenging patient positions. With a soft, comfortable, lightweight and radiolucent material, it’s engineered to uniquely bend and conform to the patient’s body while providing uniform temperatures to the patient, helping maintain normothermia. When deployed, a clear head drape and two neck vents keep warm air around the patient’s intubated head, allowing for observation during the procedure, while two re-sealable hose ports provide flexibility in positioning. • Find additional information at www.BairHugger.com.

OR TODAY | April 2017

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PRODUCT FOCUS

C CHANGE SURGICAL SURGISLUSH SurgiSLUSH provides the smartest, safest and most economical way to make surgical slush. Sterile surgical slush is used to topically cool organs during complex procedures to reduce tissue damage and allow surgeons more time to operate. Users can position SurgiSLUSH inside or outside of procedure rooms and serve multiple rooms from one machine. SurgiSLUSH creates perfectly smooth slush every time using secure, re-usable, hydrophobic containers. SurgiSLUSH creates perfect slush in 35-45 minutes then automatically switches to Maintain Mode to keep slush smooth and clump-free until needed. SurgiSLUSH is ideal for hybrid procedure rooms. The new Protective Container System provides a double-container assembly that assures sterility, simplifies sterile field dispensing and protects against tampering or unintended contamination. Erase the need for slush drapes, save valuable sterile field space and eliminate a potential source of disrupted airflows near the patient. Gain efficiency and free your staff with the newest, smartest way to make and use perfect surgical slush. â&#x20AC;˘

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April 2017 | OR TODAY

IN THE OR PRODUCT FOCUS

ENCOMPASS THERMOFLECT HEAT REFLECTIVE TECHNOLOGY PRODUCTS Thermoflect Heat Reflective Technology products from Encompass Group LLC are applied preoperatively, begin working immediately and follow the patient throughout the perioperative journey to maintain normothermia and help prevent hypothermia. Data collected from 55 evidence-based practice trials demonstrated the following improvements when incorporating Thermoflect Heat Reflective Technology products compared to standard care: 20 percent reduction in hypothermia upon admission to PACU, 17 percent reduction in perioperative heat loss for enhanced comfort and 30-75 percent savings compared to other protocols. â&#x20AC;˘ For more information about Thermoflect Heat Reflective Technology, visit www.thermoflect.com.

OR TODAY | April 2017

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PRODUCT FOCUS

MAC MEDICAL D-SERIES BLANKET AND FLUID WARMING CABINETS MAC Medicalâ&#x20AC;&#x2122;s new D-Series (Data Logging) Blanket and Fluid Warming Cabinets are user-friendly temperature recording devices. They are equipped with independent, digitally controlled heating chambers that offer actual temperature and set point displays. Simple plug-and-play data requires no additional software. These warming cabinets are available in single, dual, and triple chamber units and have many optional features including glass doors, seismic braces, roll out baskets, and sloped tops, just to name a few. With its sleek new appearance, the D-Series is sure to enhance and compliment your facility. â&#x20AC;˘ For more information, visit www.macmedical.com.

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April 2017 | OR TODAY

IN THE OR PRODUCT FOCUS

AUGUSTINE TEMPERATURE MANAGEMENT HOTDOG PATIENT WARMING During certain procedures, forced-air patient warming systems are a risk to patient safety. Mitigate this unnecessary risk by upgrading your patient warming system. HotDog Patient Warming is the only air-free and water-free system with both blankets and mattresses to warm the patient above and below simultaneously – for twice the heat transfer – which is critical for defeating hypothermia. The average cost of a hypothermic patient is $3,000 due to increased complications. That’s potentially millions of doallrs per year in added costs from failed warming. New Quality Guidelines require effective active warming. Don’t switch to ineffective underbody-only warmers – warm from above and below with HotDog, your effective air-free solution. •

OR TODAY | April 2017

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IN FO IC R IA N

PRODUCT FOCUS

POLAR PRODUCTS COOLOR VEST SYSTEM Polar Products lightweight CoolOR vest system keeps surgeons cool and comfortable by continuously circulating cold water from an attached cooling reservoir through over 50 feet of tubing sewn within the vest. Quick disconnect, dry couplings allow the surgeon freedom of movement as needed. Variable Flow Control enables staff to effectively manage the vest temperature. The Rechargeable Lithium Ion Battery Pack can power the unit for over six hours. All electrical components are UL listed. Neoprene gasket seal, high-density insulation and stainless steel compression latches ensure a leak proof cooling reservoir. Three vest styles and three cooler sizes to choose from for optimum comfort. â&#x20AC;˘

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April 2017 | OR TODAY

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IN THE OR CONTINUING EDUCATION CE460D

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

40 OR TODAY | April 2017

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CONTINUING EDUCATION CE460D

ROBOTS JOIN THE SURGICAL TEAM Imagine this scene in the OR: A surgeon who is performing a tedious laparoscopic procedure starts to experience hand-eye fatigue. The assistant holding the camera for the surgeon’s visualization experi-

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

The purpose of this program is to provide nurses with an overview of the use of robotic-assisted laparoscopic/endoscopic methods during surgery. After studying this information, you will be able to: •L ist the eight components necessary for endoscopic surgical procedures •D escribe the endoscopic functions of robotic-assisted technology • Discuss how healthcare professionals interact with robotic-assisted technology

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ences an involuntary tremor. That in turn results in motion artifacts on the video resembling an earthquake. Other members of the surgical team aren’t spared, either: They are getting “seasick” as they watch the wavering image on the screen. Obviously, all of this is affecting the team’s concentration and performance of critical tasks. Now a solution exists: roboticassisted laparoscopy. The surgical team uses a robot with three to four mechanical arms to perform complex surgery without the problem of human hand-eye fatigue — and with a high degree of precision.1 In fact, the movement possible with robotic “hands” and instrument tips is superior to that possible with the human hand. As robotic-assisted laparoscopy grows more widespread, more nurses are likely to encounter patients scheduled for or recovering from such surgery — or be members of a surgical team that uses robots. To fully appreciate the impact of robots in the OR during laparoscopy, the nurse must have a fundamental knowledge of endoscopy, which is the use of telescopes and long instruments to enter the body through a natural body orifice or a series of tiny incisions in the skin. The term “endo” means inside, and “scopy” means to look. Endoscopic procedures are usually named for the entry point location of the body, such as neuroendoscopy for the ventricles of the brain or hysteroscopy for procedures of the uterus. The use of endoscopes in abdominal surgery is termed “laparoscopy.”1 (“Laparo” means loins or flank in Greek.)

CANDLES AND TORCHES

Endoscopy has a long history, with roots in ancient Greek medicine, as in Hippocrates’ use of tubular specula for examination of natural body orifices. This was a tenuous procedure, as lighted candles and torches were used for illumination. Visualization of internal structures was poor, and procedural tissue manipulation was restricted to grasping instruments and metallic cauterization tips heated by fire. Endoscopic techniques through natural orifices improved in the 19th century as the use of mirrors and other reflecting elements enhanced illumination. But reflected illumination generated uncontrolled heat in the patient’s tissues, causing burns. (Methane in the colon was a source of combustion.) Later, small incandescent electric bulbs were used with some success. However, the risk of electrocution was significant.1 In the late 1800s, urologists and opticians made major strides in technique and safety by creating a telescope illuminated by an external light source for viewing inside a patient’s urinary bladder. This invention, the cystoscope, increased the field of vision by directing light through a lens to the interior of the working space, which was created by sterile water in the bladder. (Bladder endoscopy is called cystoscopy.)1 In the early 20th century, surgeons developed a new method to create a working space: insufflation of air into a body cavity. Surgeons experimented by using ambient air to expand the peritoneal cavity and April 2017 | OR TODAY

IN THE OR CONTINUING EDUCATION CE460D

look inside with the newly developed cystoscope. But problems included fires and explosions caused by electric sparks in an oxygen-enriched environment. Surgeons later switched to carbon dioxide (CO2), which is readily absorbed by the peritoneal membrane of the abdomen and easily excreted from the body via the pulmonary system. CO2 is nonflammable and safe for use in endoscopy.1 In the mid-20th century, surgeons refined endoscopy to incorporate the measurement of intra-abdominal pressure and the use of refined electrosurgical techniques for procedures including tubal coagulation for female sterilization. The introduc-

tion of fiberoptic technology permitted videotaping and photographing of internal structures, thus enabling more advanced procedures, such as cholecystectomy (removal of the gall bladder) and bariatric surgery. The next step was fine-tuned robotic control for precise movement within the working space.1

specimens and reestablishing the integrity of the entry point. All aspects of endoscopic or laparoscopic surgery require intervention by the sterile surgical team. The access portal and insufflation is performed by a sterile surgical team when robotic-assisted surgery is planned. The remainder of the surgical activities for the roboticassisted procedure are performed by a THE ESSENTIALS nonsterile surgeon seated at a control The integration of robotic technolo- console. A sterile team remains at gies into laparoscopy involves a series the sterile field for the duration of of steps common to all endoscopic the robotic procedure and close the procedures. The eight essentials of incision(s) when the surgery is comendoscopy incorporate methods of pleted. The eight essentials of endosentering the body, providing space for copy follow: the surgeon to handle tissue under Access portal. An access portal is direct or indirect vision, removing a natural body orifice or a set of one

CONVENTIONAL SURGERY COMPARED WITH ENDOSCOPIC AND ROBOTIC APPLICATIONS1,2,3,4 Criteria

Open Laparotomy

Laparoscopy

Robotic-Assisted Laparoscopy

Procedural duration

3½ hours

4 to 4½ hours

3½ hours

Length of stay

2-3 days

1 day

Incision length

5-7 inches

2 to 3 inches combined. 2 to 3 inches combined. Single Single port incisions are used port incisions are used for multiple for multiple instruments instruments

Closure

Multiple sutures or staples

One or two sutures at the level of the fascia. Wound glue is used on the skin

One or two sutures at the level of the fascia. Wound glue on the skin

Estimated blood loss

450 to 800 mL

400 to 500 mL

100 to 300 mL

Visualization

3-D Direct vision

2-D

3-D High resolution, binocular vision and magnification

Magnification

3X with magnifying loupes

Instrument manipulation

Human range of motion

OR TODAY | April 2017

6X, uses one camera Eye-hand coordination

10 to 12X, can use more than one camera and tile images Human range of motion in smaller scale with increased precision WWW.ORTODAY.COM

CONTINUING EDUCATION CE460D

or more strategically placed percutaneous puncture sites.4 At least one access portal is required for the creation of the working space in all endoscopy. Single-incision laparoscopic surgery permits the introduction of several instruments through one access portal in the umbilicus. A flexible spool-shaped plug with three working ports is situated through a single 2-cm incision below the umbilical stalk. Entering though the infraumbilical area allows direct access to the intraperitoneal environment via penetration of the fascial layer at the linea alba.4 The SILS portal forms an airtight seal with three access portals and an insufflation tube. Additional accessory trocars can be inserted under direct vision as needed. Working space. The working space is the surgical area in which the boundaries of the internal environment are expanded and maintained throughout the endoscopic procedure. Expansion media can be ambient air, fluid, CO2 or physiological structural support. Laparoscopy requires CO2 insufflation through blind puncture with a specialized spring-loaded Veress needle to expand and maintain a space (pneumoperitoneum) within the peritoneal cavity.4 The Veress needle has a protective ball-tip that retracts as it passes through tissue layers. Tissue depth and body habitus determine the length of the needle used, which can be between 80 mm and 150 mm. Some patients are not candidates for Veress needle use because of intra-abdominal adhesions or other physiologic reasons. A blind puncture could injure the underlying organs. An incision can be made through the skin into the peritoneal cavity and a blunt Hasson trocar can be inserted. Insufflation of CO2 for a pneumoperitoneum is done via the blunt trocar.4 WWW.ORTODAY.COM

With a SILS portal, an incision is made through the skin into the peritoneal cavity. The working space is established through a built-in insufflation tube and CO2 after three cannula sheaths have been positioned. A Veress needle is not used. Illumination. The internal environment is lighted by fiberoptics within the boundaries of the working space. The telescope delivers the light to the internal working space. The telescope is attached to the light source and is white-balanced to provide the true color of the internal landscape. Vision. Members of the surgical team observe the internal anatomy through a lighted hollow tube or a series of lenses attached to a fiberoptic camera. In laparoscopy, the surgeon observes the internal target regions within the working space with a telescope-camera assembly inserted through the primary endoscopic sheath or SILS portal. The team can see the internal images on a digital video monitor. Robotic cameras have binocular vision because of a double lens on the laparoscope. Manipulation. The surgeon examines or alters the target tissues using long, specialized instruments passed through a percutaneous sheath or working channel of the endoscope. All laparoscopic surgical techniques, such as dissection, grasping, debulking, probing and excising, take place with the instrumentation passed through the SILS or secondary endoscopic portals. SILS permits passage of two instruments and one laparoscope through one main access portal in the umbilicus. Manipulation requires visualization by triangulation of the lens and the working instruments.5 Triangulation is managed with the flexible ports in the SILS port or by placement of multiple accessory trocars through the abdomen.

In robotic surgery, the sterile team remains at the surgical site while the nonsterile surgeon sits at the console to manipulate the robotâ&#x20AC;&#x2122;s arms and instrumentation. Robotic surgery requires human intervention and is not independent of a sterile team. Capture. Target tissues are isolated and removed as surgical specimens through the SILS portal or other endoscopic sheaths. Small rolled-up plastic bags with drawstrings that look like butterfly nets are passed through one of the access portals to capture and contain the specimen. Evacuation. The specimen(s), expansion media, body fluids, irrigation and plume are safely removed from the working space by suction at the end of the surgical procedure to prevent biological contamination of the surgical team and environment. The CO2 gas contains biocontamination and should not be expelled into the room air. Closure. Access portals over 10 mm are approximated at the fascial level with suture medium to reestablish the integrity of the bodyâ&#x20AC;&#x2122;s surface at the end of the procedure. Closure at this level is necessary to prevent herniation. In children, the portals measuring 5mm are sutured.4 The skin is closed with wound glue. ENTER THE ROBOTS

Robotic-assisted technology has fine-tuned each of the eight essential steps. Advantages of robotic technology include the ability to perform more precise movements within the working space, stable 3-D visualization in binocular vision up to 12 times the magnification of standard laparoscopic approaches, and decreased human fatigue and tremor during prolonged surgical procedures. In addition, the precision April 2017 | OR TODAY

IN THE OR CONTINUING EDUCATION CE460D of motion and the acute visualization possible with robotic-assisted technology permit the surgeon to avoid many blood vessels, thus reducing blood loss.5 Disadvantages include the high cost of starting a robotic-assisted laparoscopy program (2 million to 3 million dollars) and the additional cost of $1,000 per procedure, the intensity of user training programs, surgeon and team learning curves and loss of human tactile sense, referred to as haptic sense in robotic technology.6 Most facilities require mentorship by an experienced surgeon for multiple cases when a new team or surgeon is preparing to perform robotic procedures. MOVING FORWARD

Several advances have been key in the evolution of robotic-assisted laparoscopy. The invention of the mechanical camera holder in the early 1990s virtually eliminated the motion artifact caused by unsteady human hands. Decades later, this device was developed into an automated, voice-activated system. The Automated Endoscopic System for Optimal Positioning (AESOP) is known as the first endoscopic robotic camera holder, approved by the FDA in 1994. AESOP is an articulated arm, mounted on the OR bed, that takes directions the surgeon transmits electronically via a headset and microphone. AESOP allows the physician to position the camera with voice commands, leaving his or her hands free to continue operating on the patient. At the surgeon’s voice command, the camera assumes a position and stabilizes the image without extraneous motion. Each surgeon has a voice card that individualizes AESOP’s responses to the spoken word and sorts out verbal patterns not 44 OR TODAY | April 2017

intended as instructions. Current robotic-assisted technology is led by a robotic surgical system that includes a console station a few feet from the sterile field and a remote-controlled robot with three to four mechanical arms positioned over the surgical field. The primary surgeon sits at the console to remotely manipulate the mechanical arms, which hold in place the surgical instruments. One arm is equipped with a camera; the others are fitted with surgical instruments that the surgeon controls to dissect and suture tissue during procedures. The surgeon does not touch the instruments directly during surgery. Each robotic instrument is used only 10 times. The instruments are fitted with a microchip that logs each use and informs the user when it needs to be replaced.1 In the event the procedure has to be aborted and converted to a conventional open surgery, the robotic instrument set includes wrenches to disengage the working arms without contamination. The robotic unit is moved away from the sterile field so the surgeon can scrub and don sterile attire to proceed with an open procedure.3 THE HUMAN TOUCH

Whatever the advantages and disadvantages of robots in endoscopy and laparoscopy, the human surgical team is still very much on the scene. The patient is reassured that the surgeon and team are performing the procedure rather than just the robot acting independently. Procedural setup starts at the sterile field with a sterile team of one or two surgical assistants and a scrub person, who remain in place throughout the procedure. The preincision “timeout” includes acknowledging the correct patient identification

data and the presence of the necessary equipment and supplies to perform the procedure. The circulating nurse preps the abdomen, and the sterile team drapes the patient. CO2 under pressure is insufflated through a Veress needle, SILS or Hasson trocar to create and maintain the working space as in conventional laparoscopy. The assistant surgeon inserts three or four percutaneous trocars or a SILS portal into the patient’s abdomen. If a SILS portal is not used, three or four accessory portals can be positioned in a generalized triangular pattern in preparation for insertion of a camera-telescope assembly and instrumentation after the pneumoperitoneum is established. The robot is positioned over the sterile field and attached to instrumentation inserted into the percutaneous portal(s). Only instrumentation manufactured for the robotic arm assembly can be used. One mechanical arm is designated as the director of the camera-telescope assembly. The primary surgeon at the console controls illumination and viewing by operating the robotic camera arm. The surgeon also operates the other mechanical arms for tissue manipulation and capture during the procedure. To start operating the robot, the surgeon presses his or her forehead into a face port viewer on the console. Failure to make full contact with the forehead rest causes the robot to go into standby mode as a safety feature. This prevents involuntary motion of the arms or instrumentation, which could injure nontarget tissue. The surgeon creates the fine hand motions required for the procedure by manipulating joysticks — general control devices consisting of handheld levers — in response to real-time images the camera WWW.ORTODAY.COM

CONTINUING EDUCATION CE460D

transmits to the viewfinder in 3-D stereo vision. The surgeon has an excellent view within the working space that enables precise directional motions of the robotic instrument tips and magnification as needed. The range of motion is superior to that of the human wrist in surgery. The motions generated in response to the joysticks include the following: Roll: circular rotations of the tip, clockwise and counterclockwise Pitch: linear up-and-down motion Yaw: linear side-to-side motion Insertion: linear back-and-forth motion Grip: grasp and release Clockwise rotation Counterclockwise rotation ALWAYS INVOLVED

Perioperative nurses on the surgical team are involved in transferring the patient from the transport cart to the OR bed and positioning and prepping the patient. The surface of the OR bed mattress is a nonslip material to prevent shifting of the patient’s body during repositioning of the OR bed for performance of the procedure.1 The circulating nurse secures the patient with a safety belt across the thighs and a small pillow under the knees to reduce lumbar pressure. The nurse should be able to slide one hand between the safety belt and the patient’s leg to ensure that the belt is not too tight.1 The anesthesia provider indicates when the patient can be safely moved into position for the surgical procedure.3 If the perineum is accessed, the patient’s legs are secured in stirrups. Some procedures require access to the rectum, such as robotic-assisted prostatectomy, for palpation of the prostate.5 After the patient is positioned, the circulating nurse preps the surgical site with antiseptic solution. The WWW.ORTODAY.COM

sterile team applies sterile drapes, leaving the abdominal surgical access points exposed. Ideally, the nonsterile components of the robot are draped at the same time the patient is draped. However, some facilities have the robot draped before the patient enters the OR. Some robotic arms clamp directly to the operating bed. Other devices are on wheels and are rolled up to the patient’s side and locked into position. Locking the mechanism is critical because any unintended movement of the robot during the procedure could cause misalignment of the robotic arms with the surgical planes of the patient. Tissue injury could result. Care is taken not to contaminate the sterile-draped robotic arms as they are attached to the sterile instrumentation used inside the patient’s body. The assistant surgeon makes the tiny incision in the infraumbilical margin required to insert the Veress needle or infraumbilically to insert the SILS portal to create the pneumoperitoneum. The CO2 flows into the patient’s peritoneal cavity at pressures of 12 mmHg to 14 mmHg,1 Patients with a large body mass having bariatric procedures may require pressures up to 18 mmHg to compensate for the weight of abdominal tissue.1 Some hospitals use a CO2 warmer because the gas is cold in its gaseous state in the tank. CO2 is not sterile, so the delivery tubing has an inline filter to collect particulate before the gas enters the patient. If a SILS port is used, the working space is created by the insufflation port on the side of the device. The camera and instrumentation are inserted through the 10 mm- or 5 mm-ports. If the working space is established with a Veress needle, the assistant surgeon slightly enlarges the infraumbilical skin incision and

percutaneously inserts a 10-mm to 12-mm primary trocar for placement of the high-resolution telescope-camera assembly secured in a robotic arm. Several accessory port trocars are inserted through the skin. The illuminated light cable is attached to the laparoscope. Never permit a lighted fiberoptic cable to rest on the drapes; it could cause a fire. The CO2 tubing is switched from the primary access sheath to a secondary port to minimize lens fogging caused by the cold gas.1 Instrumentation attached to the robotic arms is inserted through the portals and positioned within the patient’s body. The primary surgeon manipulates the instruments and camera from the console several feet from the patient. The surgeon uses joysticks and foot pedals to perform the procedure while watching through the forehead-pressure viewfinder. Electrosurgical dissection and specialized powered instruments are used during the surgical procedure. A microprocessor in the robot records each motion action as documentation of the surgery and as a teaching aid for robotic teams in training. ON THE ALERT

The sterile team remains at the sterile field to change instrument tips during tissue manipulation and specimen capture. The entire team observes the patient for reactions to procedural manipulation and for physiological status. The anesthesia provider observes for blood pressure, pulse, respiration, oxygenation and potential complications of air or gas in the abdominal cavity. Changes in body temperature are monitored throughout the procedure because hypothermia caused by the low-temperature CO2 could complicate the outcome.3 April 2017 | OR TODAY

IN THE OR CONTINUING EDUCATION CE460D At the end of the procedure, the CO2 is evacuated through the suction tubing. The skin access incisions are sutured or closed with other closure media. Small bandages are applied if needed.

STAYING FLEXIBLE

Possible complications of robotic-assisted laparoscopy include perforation of untoward structures and tears in tissue under tension. A stray electrical

current or heat from electrosurgical tips can injure tissue, and injuries may not be manifested until several days after surgery. Hemorrhage can obscure the surgeon’s vision through the lapa-

CLINICAL VIGNETTE Mr. Elliott has prostate cancer and will have a radical prostatectomy. He is referred to a surgeon who uses robotic-assisted laparoscopy. While obtaining informed consent, the surgeon explains the procedure to Mr. Elliott: A radical prostatectomy is the complete excision of the prostate seminal vesicles, the ends of the vas deferens and the areas of the surrounding nerves, blood vessels and fat. The procedure is first-line treatment for prostate cancer. The procedure is performed under general anesthesia to prevent movement of the patient, which could interfere with surgery. Mr. Elliott asks about the benefits and risks of robotic surgery. The surgeon explains that the visualization is exceptional, better than the naked eye, and the precision of the instrumentation offers better control than the surgeon’s hand. Robotic techniques spare nerve damage for bladder control and potency, with 94% of men regaining urinary continence within six months. The use of robotics minimizes blood loss and reduces postoperative pain. Most patients stay in the hospital one or two days while the tiny, minimally invasive incisions begin to heal. Studies show that patients return to daily activities within 10 days after surgery. 1. Which of the following is an advantage of using robotic-assisted techniques? a. Less blood loss b. Shorter surgery time c. Lowered procedural cost d. Less prostate removed

4. Correct Answer: B — Robotic techniques spare nerve damage for bladder control, with 94% of men regaining urinary continence within six months.

2. Correct Answer: D — Mr. Elliott’s potency may be preserved because of the nerve-sparing ability of the robotic instrumentation.

3. Correct Answer: C — Robotic-assisted prostatectomy is performed under general anesthesia because the patient’s physiology must be carefully controlled.

1. Correct Answer: A — The precision and the acute visualization of robotic-assisted techniques enable the surgeon to avoid many blood vessels, which decreases blood loss.

2. Informed consent for a radical prostatectomy performed with robotic techniques includes what information? a. The incision will be about 7 inches long. b. Urinary control will be totally lost. c. The procedure provides a total cure. d. The patient’s potency can possibly be spared.

3. Robotic-assisted prostatectomy is performed under which of the following anesthetic methods? a. Local anesthesia b. Epidural anesthesia c. General anesthesia d. Spinal anesthesia 4. What percent of men regain urinary continence within six months of a radical prostatectomy performed with robotic techniques? a. 100% b. 94% c. 84% d. 78%

OR TODAY | April 2017

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HOW TO EARN CONTINUING CONTINUING EDUCATION EDUCATION CREDIT CE460D

roscope and require the sterile team to convert from a laparoscopic procedure to an open laparotomy. The team must always be alert to this possibility and have the knowledge and skill to safely disconnect the robot. When this situation arises, instrumentation, sponges and sharps from the laparoscopic procedure are accounted for and kept separate from the countable items used for open laparotomy.1 Each facility should establish robotic procedure competencies for the surgeons and staff to perform surgery safely and efficiently. Robotics has revolutionized surgical patient care. Currently, the surgeon and the console are located in the same room as the patient’s robotic procedure. One day, surgeons may be able to operate remotely on patients in distant locales. The field of robotics is expanding, and robotic-assisted techniques are taking the surgeon, the perioperative nurse and the patient into a realm of precision never before imagined. OnCourse Learning guarantees that this educational activity is free from bias. Nancymarie Phillips, PhD, RN, RNFA, CNOR(E), is a professor of perioperative education for perioperative nurses and surgical technologists at Lakeland Community College in Kirtland, Ohio. She is the author of several textbooks and articles, and received the Lakeland Excellence in Teaching, the Association of periOperative Registered Nurses’ Perioperative Clinical Educator and the Sigma Theta Tau Virginia Osalvsky Mentorship awards. References 1. Phillips NM. Berry and Kohn’s Operating Room Technique. 12th ed. St. Louis, MO: Elsevier; 2012. 2. Chan KG, Collins JW, Wiklund NP. Robot-assisted radical cystectomy: extracorporeal vs intracorporeal urinary diversion. J Urol. 2015; 93:1467-1469. 3. Cockcroft J, Berry CB. Anesthesia for major urologic surgery. Anesth Clin. 2015;33:165-172. 4. Stranz C, Baker C, Singh S. Abdominal access techniques (including laparoscopic access). Surg. 2015;3:200-205. 5. Alemozaffar M, Sanda M, Yecies D, Mucci LA, Stampfer MJ, Kenfield SA. Benchmarks for operative outcomes of robotic and open radical prostatectomy: results from the health professionals follow-up study. E uro Urol. 2015;67:432-438.

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

DEADLINE Courses must be completed by 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 and the District of Columbia Board of Nursing (provider # 50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider # CEP16588.

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

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

6. Williams SB, Prado K, Hu JC. Economics of robotic surgery. Urol Clin North Am. 2014;41:591-596. WWW.ORTODAY.COM

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CORPORATE PROFILE

GET TO KNOW D. A. SURGICAL

ur founder, R. Dan Allen, has been passionate about patient positioning for over 37 years. He is the retired founder of Allen Medical Systems as well as the inventor of the Allen® Stirrup, TrenGuard™ Trendelenburg Patient Restraint, ArmGuard™ Patient Arm Protector and many other solutions to contemporary patient positioning problems. Many of his devices are the standard of care in hospitals around the world. He is a published author on the topic of patient positioning and has been an invited speaker on the subject of patient positioning in the operating room at an AORN Congress and a number of local and regional AORN chapter meetings. His talk on Trendelenburg Positioning for Robotic Surgery was presented as a CE webinar and as a CE presentation at the O. R. Managers Conference in 2015 and 2016. WHY DOES D. A. SURGICAL EXIST?

A number of years ago Dan was invited to attend several early roboticassisted procedures. On several occasions, upon removal of the drapes he observed that the patient’s position had changed, sliding towards the head of the table. That patient movement presented in the form of reduced leg flexion in the stirrups. When he asked how the robot compensated for the sliding he was surprised to learn that the robot was not programmed to detect patient sliding. It occurred to him that if the robot did not compensate for patient sliding, there must be a substantial risk for injury at the laparo50 OR TODAY | April 2017

scopic entry sites. Further research into gynecology literature confirmed his concerns. Upon learning that there were no guidelines or standards of care for the unique patient positioning requirements of robotic surgery, he envisioned several devices that could solve unmet needs for Trendelenburg positioning in robotic surgery. Dan’s passion for developing patient positioning solutions got the best of him and he came out of retirement “one last time.” He spent the past five years focused on developing devices that solve the unique patient positioning requirements that have presented themselves with the introduction of robotic-assisted surgery. His efforts led to the founding of D. A. Surgical and the sourcing and development of a comprehensive family of robotic surgery positioning devices that accommodate both high-BMI and smaller patients. Each device can be used separately or may be integrated into a complete robotic surgery positioning system. Components include: PatientGuard™ Robot Stirrups, TrenGuard™ Trendelenburg Patient Restraint, ArmGuard™ Arm Protector, FaceGuard™ Table Mounted Instrument Tray and face protector, PatientGuard™ High BMI table

R. Dan Allen D. A. Surgical Founder

surfaces and PatientGuard™ High BMI Stirrup Width Extensions. The versatility of these devices also allow them to be used to enhance the positioning of patients undergoing contemporary minimally invasive surgical procedures. HOW IS POSITIONING FOR ROBOTIC SURGERY DIFFERENT?

Creating a safe environment for patients in the Trendelenburg position has always been challenging. Robotic surgery technology created patient safety risks that never presented with conventional minimally invasive surgery. These risks are exclusive to robotic surgery and require complete patient immobility to avoid patient injury. Even minimal patient sliding can result in unnecessary patient injury. The literature makes clear that patient sliding on the table WWW.ORTODAY.COM

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D. A. Surgical’s ArmGuard™ Patient Arm Protector secures and protects arms without hindering clinical access.

during robotic surgery should be considered a “never event.” Dr. Ali Ghomi articulated this problem in his paper “Robotics in Practice: New angles on Safer Positioning” published in Contemporary OBGYN in October, 2012. There, he states “Patient slippage during the use of fixed robotic trocars creates a serious potential for patient risk.” The surgical robot is not programmed to detect and then compensate for the change in patient position caused when the patient slides on the table during surgery, often resulting in the patient hanging on the trocars. The risks of this positioning failure according to Dr. Ghomi are “incisional tear, post-operative hernia formation, and increased postoperative pain secondary to overstretching of the anterior abdominal wall.” WHAT GUIDELINES CAN PEOPLE USE FOR ROBOTIC PATIENT POSITIONING?

Clinicians have expressed frustration at the lack of formal guidelines in this area. There is little information beyond WWW.ORTODAY.COM

what not to do, and some descriptions from robotics early-adopters describe how off-label use of miscellaneous materials helped them restrain patients. To that end we offer a one-hour CE webinar on safe Trendelenburg positioning for presentation at local and regional AORN chapter meetings. More information on our CE program as well as a positioning webinar will soon be available on our website. WHAT ARE THE DANGERS OF USING MISCELLANEOUS MATERIALS TO POSITION PATIENTS IN TRENDELENBURG?

When creating “homemade” restraint devices, like the use of tape and foam or tape and a gel pad, clinicians attempt to stabilize patients to the table without interacting with the brachial plexus. In doing so, they are, in fact, using products in an “off label” manner and the literature actually describes patient sliding as the result of using miscellaneous materials. The off-label use of these materials for Trendelenburg positioning supersedes the most basic

FDA guidelines: there is no testing, no analysis, no methodology and certainly no quality control. If, in an attempt to keep a patient from sliding on an OR table, clinicians utilize materials in an unintended manner, each member of the surgical team and the institution are fully liable for any post-operative positioning related patient discomfort or injury. One robotic coordinator recently summed it up best, “We spent over a million dollars on a robot and now tape our patients to the table. …it’s ridiculous to do this when we could have a device specifically designed for our needs in robotic surgery.” WHY DO CLINICIANS PREFER YOUR DEVICES FOR ROBOTIC SURGERY?

TrenGuard™ Trendelenburg Patient Restraint developed a stellar reputation for product efficacy, patient safety and stability, proved efficiencies, and ease of use. Clinicians are often introduced to our devices by our network of representatives, at clinical congresses, and by way of personal references from respected April 2017 | OR TODAY

CORPORATE PROFILE

colleagues. New customers contact us out of a need to solve robotic positioning issues and find our product range to be the right answer. To that end, our products are being recognized on a global basis as meeting the otherwise-unfilled clinical requirements for positioning patients during robotic and conventional minimally invasive surgery. In 2015, our Trendelenburg Positioning System for Robotic Surgery earned the first place award for Excellence in Surgical Products and was presented to us by Surgical Products magazine in the category of Surgical Tables, Positioning and Accessories. ARE THERE ANY CLINICAL ARTICLES OR CE PRESENTATIONS THAT DESCRIBE THE EFFICACY OF YOUR TRENGUARD TRENDELENBURG PATIENT RESTRAINT TECHNOLOGY?

The presentation “Preventing Patient Sliding in Steep Trendelenburg” by Jan Barber, BSN, RN, may be the most recent published presentation describing the efficacy of a contemporary Trendelenburg restraint for robotic surgery. The poster was introduced in September, 2016 at the 29th Annual O. R. Managers Conference. The author describes the “speed bump” design of the TrenGuard™ Trendelenburg Patient Restraint and provides irrefutable evidence of its success using a sample of “503 laparoscopic and robotic gynecological cases performed over 10 months.” She describes that a rigid patient support frame that accommodates a bolster designed to fit into the body concavity (curve of the neck) is connected directly to the table with clamps. “Patients were supported with ‘speed bump’ bolster positioners that engage a large muscle mass such as the trapezius muscle.” In conjunction with the “speed bump bolster” there are non-load bearing lateral stabilizing pillows to control body mass shift during the transition between supine and Trendelenburg. “This security al52

OR TODAY | April 2017

lows patients to avoid injuries to skin, joints and nerves that are associated with sliding. Patients were inclined in steep Trendelenburg at a 30-40 degree angle. No patients slid on the OR bed. There have been no skin shearing or brachial plexus injuries.” BESIDES TRENDELENBURG POSITIONING, WHAT’S ANOTHER CHALLENGE YOUR CUSTOMERS FACE?

It seems that as early as 2009, the AORN felt that there were enough upper extremity injuries caused by tucking patient arms with the draw sheet that they published patient positioning guidelines that recommended that “patient arms should not be tucked in the supine position.” unless absolutely necessary due to increased risk of injury to the patient. Very few nurses are aware of this guideline and even fewer follow it. There simply wasn’t a viable alternative offered by the medical device industry until we developed and introduced our ArmGuard™ Patient Arm Protector. We are told that clinicians appreciate how ArmGuard™ provides safer arm restraint, allows immediate unobstructed access to ports and lines in an emergency, and has a low profile that is comfortable for the assistant and eliminates clashing with the robot arms. In 2016 our ArmGuard™ Positioning System earned the first place award for Excellence in Surgical Products and was presented to us by Surgical Products magazine in the category of Surgical Tables, Positioning and Accessories. WHAT ADVANTAGES DO YOU OFFER IN COMPARISON WITH YOUR COMPETITION?

As a small company we are able to respond quickly to the continuously changing surgical environment. A good example is how we quickly met the needs of a major university hospital in Michigan that requested that we create a specialized positioning system for infants and adolescents. Further, our products also translate

“ This security allows patients to avoid injuries to skin, joints and nerves that are associated with sliding. Patients were inclined in steep Trendelenburg at a 30-40 degree angle. No patients slid on the OR bed. There have been no skin shearing or brachial plexus injuries.” well for use in the broader surgical arena, outside our area of focus in robotics and gyn, without any adjustments in the products or their uses. WHAT IS NEW AT D. A. SURGICAL?

The most recent addition to our positioning accessory offering is an innovative booted surgical stirrup designed specifically for robotic surgery. The PatientGuard™ Robot Stirrup allows lower leg positioning which results in faster and easier docking and improved bedside access. Our stirrup is familiar to use and provides previously unavailable positional and ergonomic benefits for surgeons and clinicians when contrasted with their existing surgical leg holders. D. A. SURGICAL GOES GLOBAL!

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SHIFT CHANGE OR Staffing Shortage BY DON SADLER

ike the iceber sunk t g that he Tita there â&#x20AC;&#x2122;s a loo nic, ming threat o that c n the horizo ou n conse ld have dire quenc es for periop erativ e ing. W eâ&#x20AC;&#x2122;re t nursalking about a shor tage of OR nurse s.

SHIFT CHANGE

COVER STORY

OR Staffing Shortage

This shortage has been attributed to two main factors: the retirement (or pending retirement) of OR nurses who are in their 50s and 60s, and the lack of specialized perioperative training for nurses during their clinical education. “The OR nursing shortage is particularly impacted by the absence of perioperative clinical practice and curricula in most nursing programs,” says ChrysMarie Suby, RN MS, the president and CEO of the Labor Management Institute. “This reduces interest in and awareness of employment opportunities in the OR environment among new nurse graduates.” ChrysMarie Suby, RN, MS, President and CEO of the Labor Management Institute.

OR TODAY | April 2017

THE AGING NURSE POPULATION

As for the aging OR nurse population, about two-thirds of perioperative nurse leaders today are over 50 years old and one-fifth are over 60. Also, 37 percent of OR nurses say they plan to retire within the next three years and 65 percent plan to retire by 2022. “We are observing the impact of the nursing shortage on a daily basis,” says Janet Chadwick, Manager, Education and Quality, Perioperative Services at UNC Hospitals in Chapel Hill, North Carolina. “All managers in our area are discussing the same concerns,” Chadwick adds. “And all hospitals within our health system are experiencing issues with recruitment of specialty skilled nurses, including OR nurses.” In West Bloomfield, Michigan, Lakes Surgery Center Administrator Jennifer Butterfield, MBA, RN, CNOR, CASC, says she anticipates a significant OR nursing shortage within the next few years, especially in hospitals. The average age of OR nurses at Butterfield’s surgery center is 50 – the oldest is 64 and the youngest is 35, she says.

“The biggest challenge will be to replace the extensive knowledge and experience of retiring OR nurses,” says Butterfield. “These are the RNs who have experience as both circulators and scrub nurses and in all specialties.” Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, the CEO and Executive Director of the Association of periOperative Registered Nurses (AORN), concurs. “Now that the economy has improved, the experienced nurses are beginning to retire and the ‘brain drain’ of knowledge is resulting,” says Groah. “The experienced nurses are taking 30 to 40 years of nursing knowledge with them.” “If you have an OR nurse who is retiring, this is going to leave a gaping hole in your team,” says Butterfield. “What employers often don’t see is that the retiring nurse was the unofficial person everyone else went to with questions.” “To replace this person, employers will have to look beyond the job description and hire someone who is willing to wear multiple hats,” Butterfield continues. “He or she must be motivated to learn the ‘why’ behind what is being performed in a surgery.” CYCLICAL SHORTAGES

Chadwick says that OR nurse shortages are cyclical in her university setting. “This current cycle seems to be much longer and more severe than in other years, however,” she says. According to Butterfield, another staffing challenge is that perioperative nurses are becoming highly specialized. “This means they are really great at one or two service lines but have limited experience in other lines,” WWW.ORTODAY.COM

N ow that the economy has improved, the experienced nurses are beginning to retire and the brain drain’ of knowledge is resulting. The experienced nurses are taking 30 to 40 years of nursing knowledge with them.'’

'’

’

-Linda Groah

she says. “This type of specialization creates staffing challenges because nurses ready and willing to perform cases often are not able to jump into other service lines to help. “In a multispecialty center, this means my orientation and training time is extended,” Butterfield adds. “For service lines that my ASC does not frequently see, such as urology, the experience in the room can be like ‘50 First Dates.’ ” Groah says that one of the biggest challenges with the perioperative nurse shortage is that most student nurses do not have exposure to the operating room during their clinical training. “Therefore, they do not know what the OR is like as a specialty,” says Groah. “Also, many facilities will only hire experienced OR nurses since it takes from 6 to 12 months to be trained as a fully functioning periWWW.ORTODAY.COM

operative nurse capable of taking call for emergency surgery,” Groah adds. According to Groah, the training costs for one RN can be between $65,000 and $75,000. “However the loss of revenue for an operating room that is not staffed for one shift can be between $160,000 and $200,000,” she says. PREPARING FOR THE SHORTAGE

Butterfield believes that the best way to prepare for the looming OR nurse shortage is to be proactive and plan ahead. “The worst thing an employer can do is ignore the signs,” she says. “Employers need to review the ages of their OR nurses and listen to the needs of their perioperative team leaders,” Butterfield adds. “Also, succession planning is a must and should start at least two to three years before the time when you think it will be needed.”

Linda Groah MSN, RN, CNOR, NEA-BC, FAAN, CEO and Executive Director of AORN

April 2017 | OR TODAY

SHIFT CHANGE

COVER STORY

OR Staffing Shortage

'’ Jennifer Butterfield, MBA, RN, CNOR, CASC Lakes Surgery Center Administrator

The worst thing an employer can do is ignore the signs. Employers need to review the ages of their OR nurses and listen to the needs of their perioperative team leaders. '’ -Jennifer Butterfield

“Facilities need to look at the big picture, review their current workforce and project its retirement status,” says Groah. “This way, experienced nurses can serve as mentors to new nurses prior to retiring.” Groah also stresses the need for conversations with members of the C-suite regarding what the loss of revenues will be if ORs do not have trained nurses. “This should include discussions about the delivery of safe patient care as well as patient and physician satisfaction,” she says. Groah says that some facilities have started nurse residency programs to help bridge the gap between education and professional practice. “Training programs and education resources like AORN’s Periop 101 are excellent recruitment tools for novice OR nurses,” says Groah. FOCUS ON RETENTION

Once new OR nurses are recruited and hired, attention must be turned to retaining them. 58

OR TODAY | April 2017

“Retention is a strong focus for all managers in our hospital,” says Chadwick. Butterfield recommends trying to hire OR nurses who want to continuously learn. “Once you have hired such OR nurses, continue to challenge them,” she says. “In my experience, nurses who are engaged and involved in more than just coming to work tend to stay longer,” says Butterfield. “Thirty percent of my staff has been at the center over 10 years – all of these nurses do things outside their normal job description.” Suby recommends creating a pipeline for getting newly hired OR nurses through orientation and building their experience as quickly as possible. “This pipeline should take them from novice to beginner to experienced RN,” she says. “The goal is to provide new hires with experience that builds on itself to help get them comfortable as quickly as possible while also promoting patient safety.” In addition, hospitals should create a strategic plan that works with local nursing programs to introduce nursing students to OR and perioperative nursing as a career, Suby adds. “Offer opportunities that allow nursing students to shadow an experienced RN or Preceptor to learn about OR nursing and get excited about it as a career,” says Suby. “Also consider offering opportunities for clinical experience with these programs, and document the number of new graduates you are able to recruit into your vacant positions.” Finally, Butterfiled stresses the importance of providing unequivocal support for new OR nurses. “I’m sure that new OR nurses would much rather hear, ‘We’ll help you every step of the way’ from their supervisors than, ‘Sink or swim!’ ” WWW.ORTODAY.COM

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SPOTLIGHT ON KATE LOCKE By Matt Skoufalos

ate Locke can recall vividly when she first believed that she might be cut out for pediatric nursing. Locke was interviewing for a position at the Children’s Hospital of Philadelphia (CHOP), and saw a young patient come past with a nurse in tow. The child was attached to a feeding pump, but that didn’t stop him from romping past with his Little Tikes pushcar, happy as could be. “I didn’t have any experience with sick kids, but he was smiling and playing, and something just clicked,” Locke said.

“" There's something about kids and being there for the parents... You have to be their rock, and you have to be OK doing that."”

Later, she found she’d happened upon an axiomatic truth. “Kids could have a day to live, and all they want to do is watch a movie and go to the playroom,” she said. Before she was hired at CHOP, Locke was placed there for the work-study component of her undergraduate degree program at Drexel University in Philadelphia. An early interest in geriatric nursing dissolved away once she was in the pediatric setting, and as a result, she’s spent the past 11 years at CHOP. Locke started in the pediatric intensive care unit (PICU) and transitioned to the cardiac catheterization lab almost five years ago. “I’ve seen everything,” she said. “We have our own cardiac ICU, which just furthered my education. It’s a total change of pace.” Locke said the differences in the pace and nature of the jobs in the two units present distinct challenges. Although she misses the close patient work she enjoyed in her previous role, the technological advancements in which she’s participated in the cath lab, including its lymphatic program, have been nothing short of groundbreaking. Working with physician Yoav Dori, Locke said she’s gotten a close look at one of the least-understood systems of the body, and has met patients from all over the world. “Your lymphatic channels are microscopic,” she said. “[Dori] finds the pathway, closes it off, and he’s been able to cure things that have never been cured before. When we follow up with him, we’ll find out that kids lost all the weight from the fluid that they were collecting and they’re back in school.” Still, Locke said she isn’t ready to give up entirely on the idea of a career with more of a focus on 62

OR TODAY | April 2017

bedside care. She knows that her skills as a nurse will ever be at least partially contingent upon her ability to deal with patients and their personalities, and Locke said that keeping those tools sharp is a constant challenge. “New nurses are getting a reputation of not being able to help themselves because they’re always on their computers,” she said. “When I started, it was half and half, so you had to rely on your instincts.” “I feel like we have two different lives,” she said. “In the PICU, I really bonded with the families. It’s different in the procedural areas.

Going into the cath lab, you lose a lot of your patient care and one-on-one time. I’m not ready to get rid of that. I enjoy working with patients and their families. It’s really important so we don’t lose our basic skills.” Many nurses can trace their roots in the career to an interest inspired by a parent or relative, and although Locke doesn’t have a family lineage in the profession, her children may one day say otherwise. Now in her third pregnancy, all of which she’s undertaken while working at CHOP, Locke said the support of her coworkers has been instrumental.

Finnley, Josh, Kate, and Piper Locke WWW.ORTODAY.COM

“I’m one of the youngest in the cath lab,” she said; “everybody has already had kids, and they all understand. I’m really lucky.” Of course, being a parent of young children and a pediatric nurse, Locke is particularly sensitive to the impact of health and safety concerns that affect children. Her concession to the dual nature of her responsibilities is to focus on the care of her patients with the love of a family member. “I feel like when we bring them into the procedural area, you treat them like they’re your own kids,” Locke said. “You’re their voice.” “There’s something about kids and being there for the parents,” she said. “You have to be their rock, and you have to be OK doing that.” In addition to working on a modified schedule during her pregnancy, Locke also operates a home-based small business called Infinnity Kids. It began as a side pursuit when her daughter, Finnley, was five months old, and Locke started making clothes for her. “I hated [store-bought] bibs,” Locke said, “but I love seeing kids wearing stuff that I made.” When pictures of her children in handmade accessories started popping up, friends and family asked where they could get some. She opened an Etsy.com shop on

WWW.ORTODAY.COM

her birthday three years ago, and it’s been growing ever since. Infinnity Kids now offers bibs, headbands, bowties, hair clips, bags and purses. “We’re trying to get into more stores; that’s the next step,” Locke said “I went to school for nursing, not business, but I design and make everything myself. I sketch it out and sew it up and fiddle with it.” Locke said she’s “always been very crafty.” Making clothes is a hobby she traces to the punk rock aesthetic of middle school, when she spent days with an old sewing machine her mother called “the tank.” “I always had my own style,” Locke said. “I used to cut up my jeans and make bags. I’m a fabric hoarder.” Although she said she’s never taken a sewing class, Locke is committed to continuing her nursing education, and could see her career someday transitioning into community health and patient/family education. She also credits the strength of her Drexel co-op education with helping her develop the critical foundation in nursing that helped solidify her career path. “Nothing is as effective as having that experience,” Locke said. “The tests that you have to take, the licensing, was easier because I had hands-on experience.”

“ " I feel like

when we bring them into the procedural area, you treat them like they’re your own kids .”" ”

April 2017 | OR TODAY

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OUT OF THE OR FITNESS

ENERGY EXPRESS BY MARILYNN PRESTON

THE SCIENCE OF GOING SMALL

START WITH YOUR SACRUM

hen we humans imagine ourselves “exercising,” we tend to focus on playing sports, working out on machines, going for a 30-minute walk. Yes! All great ways to boost your energy and give your body the juiciness and joy it deserves.

But don’t limit your exercise routine to these big-picture pursuits. There is the outer game – played out on tennis courts and treadmills – but there’s an inner game, too, going on inside every nerve, cell, muscle and bone of your body. And if you’re not playing in that arena of body awareness, you’re missing out on a wonderful, almost magical, opportunity to improve your well-being. SENSE YOUR SACRUM

Let’s focus on the sacrum, to begin to shift your thinking. Do you know precisely where yours is? You should. Your sacrum – the Greek word for sacred bone, where Greeks believed the soul resides – is holy ground when it comes to the health of your low back, your legs, your everything. 66

OR TODAY | April 2017

It is centrally located at the base of your spine and if it’s not stable, strong and in balance, it can pinch, bite and break you, in the form of a back pain, leg pain, numbness, tingling and worse. The inner game begins as you connect to your skeletal-muscular self, using an anatomy book for guidance, or learning from a master teacher, or engaging with the detailed images at www.innerbody.com, where you can pilot through the body using 3-D rotating images. So, zoom in on the sacrum, the large triangular shaped vertebrae that joins up with your hip bones to form your pelvis. Admire the architecture, front and back, right and left side. Notice how it sits between the two pelvic crests

(called the ilium). Now find your own sacrum. Frame your two hands around it. I like to relax my thumbs onto my pelvic bone and flip my fingers around so they are pointed toward my spine, resting on both sides of the sacrum. Hello sacrum. How ya’ hanging? ANATOMY IS DESTINY

Between the sacrum and the ilium is the notorious sacroiliac joint, or SI joint. The SI joint – the star of many a yoga class – stabilizes your pelvis and lower spine whenever you do any kind of movement. See how important your sacral region is? And here’s another ain’t-naturegrand fact. When you’re young, your sacrum starts out as five individual bones, or vertebrae. During late adolescence, the five vertebrae begin to merge, and by the time most of us are 30 years old, our sacrum has formed into one single bone, roughly the size of your hand. Your sacrum is a very strong bone, because it has to be. Besides protecting all the spinal nerves of the lower WWW.ORTODAY.COM

FITNESS

No More

back, and the entire female reproductive system, the sacrum supports the weight of the upper body as it spreads across the pelvis, into the legs. It also locks the hip bones together on the back and supports the base of the spinal column as it interacts with the pelvis. The bone itself has a spongy interior, and appreciates nourishing fluids.

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A HAPPY SACRUM IS A BALANCED SACRUM.

Once you focus on the architecture of your sacrum – complex, connected – you’ll understand why having a sense of it makes sense. How does your sacrum feel when you gradually bend forward from the waist slowly? Or arch your back? Is there tightness? Imbalance? Are there twinges? Self-care begins when you sense and listen to your body, to the clues it is giving you about how it feels, what it needs. And what it needs in the sacral region is stability, strength and enough juice to keep the nerves that pass through the sacrum moist and happy. Which brings us back to exercise, and the science of going small, with Somatics training, yoga, qi gong, the Alexander Technique, Feldenkrais and more. Even the best doctors were flat-out wrong when they used to tell people with low back pain to go to bed and rest their back until it got better. The opposite is true. Now doctors will tell you that it’s slow, subtle, gentle exercise that helps ease the pain and promotes healing. Marilynn Preston is a healthy lifestyle expert, well-being coach and Emmywinning producer. She is the creator of Energy Express, the longest-running syndicated fitness column in the country. She has a website, marilynnpreston.com, and welcomes reader questions, which can be sent to MyEnergyExpress@aol.com. WWW.ORTODAY.COM

April 2017 | OR TODAY

OUT OF THE OR HEALTH

BY HILARY MEYER EATINGWELL.COM

YOUR DINNER PLAN TO EAT CLEAN FOR A WEEK

f you’re trying to give your eating habits a minimakeover this year, try cutting back on some of the less-than-healthy ingredients in your diet: saturated fat, refined grains, processed foods, sugar and salt. Eating “clean” doesn’t have to mean spending tons of time in the kitchen or eliminating whole food groups from your diet. Instead, focus on convenient, fresh meals that are quick to prepare so you don’t feel tempted by highly processed convenience foods. Here’s a guide to getting “clean” meals on your table in 30 minutes or less – a perfect strategy for a weeknight dinner.

RELY ON QUICK-COOKING WHOLE GRAINS

Trying to eat clean means avoiding refined grains like white pasta, white bread and white rice in favor of whole grains. Unfortunately, a lot of whole grains take close to an hour to cook, which isn’t ideal when you’re in a rush. You have two options: a) cook a big batch of grains like barley, brown rice or wheat berries ahead to use throughout the week; or b) familiarize yourself with 68

OR TODAY | April 2017

some quick-cooking varieties like quinoa, bulgur or farro. CHOOSE YOUR VEGGIES WISELY.

Eating clean is easy when you cram as many vegetables as possible into your meal. On weeknights, try to focus on a few vegetables that cook quickly and that take very little time to prep. Snap peas, snow peas, asparagus, broccoli florets and cauliflower require little to no prep and all cook quickly (be sure to cut broc-

coli and cauliflower into small florets to speed up cooking). And they all taste good if they’re tender-crisp – a texture that’s achieved with only a few minutes of cooking time. ADD FLAVOR WITH HERBS AND CITRUS INSTEAD OF SALT.

To make your food really flavorful when you cut back on salt, you need to rely on healthy flavor-packed ingredients, such as herbs or a squeeze of fresh lemon or lime juice. For rushed weeknight dinners, choose fresh herbs that are easy to work with, such as basil and chives. And when you’re really pressed for time, dried herbs are an easy solution. If your recipe calls for fresh herbs and you want to use dried, cut the amount by one-third. USE FRUIT INSTEAD OF SUGAR TO SWEETEN DISHES.

When it comes to dessert, choose foods that are naturally sweet, such as fruit. Whirl up berries in a blender and stir together with nonfat plain yogurt and a splash of vanilla extract. WWW.ORTODAY.COM

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aving a hard time loving the new healthy foods you should be eating? It can be a challenge – particularly if you feel like you’re forcing yourself to eat certain foods. The good news: There’s new research that suggests it’s possible to embrace good-for-you foods by learning to use all five senses. “A food’s texture, how it sounds, how appetizing it looks, and how it smells all play a role in flavor perception,” says Barb Stuckey, author of “Taste What You’re Missing: The Passionate Eater’s Guide to Why Good Food Tastes Good.” Here are some ways you can use all your senses to learn to love healthier foods. 72

OR TODAY | April 2017

FOOL YOUR NOSE

It may not be the taste of Brussels sprouts, cauliflower or broccoli you hate, but the smell. Cooking cruciferous vegetables releases sulfurous compounds (the same compounds that deliver cancerfighting benefits). Try steaming them or roasting them, which releases the smelliest compounds, and then eat them in another room from the kitchen. When it comes to foods you love, strong complementary

aromas (like a whiff of coffee in a mocha dessert, vanilla beans in sugar) help you take smaller bites, a natural response so you are not overwhelmed with flavor. Try lighting a vanilla-scented candle at dessert time. TRAIN YOUR TONGUE

Here’s the secret to getting kids to learn to love veggies: it’s actually OK to add a tiny bit of sugar. Researchers found that after three days of eating broccoli and cauliflower dipped in a mixture of water and 20 percent sugar, people’s tastes even for the unsweetened vegetables improved. If you already have a sweet tooth, you can use a similar stratWWW.ORTODAY.COM

NUTRITION

egy by cutting back on all sweet tongue will get a similar sensation foods, especially those with artifito what it gets with salty foods. cial sweeteners. Often those artificial sugars are many times sweeter TWEAK THE TEXTURE than regular sugar and stimulate The more texture or viscosity a the reward area of your brain, food has, the more its taste will causing you to, in turn, crave even linger in your mouth. Think about more sweets. how a sip of a smoothie coats your “If you gradually cut artificial tongue long after a soda would sweeteners from your diet, you have been guzzled down. Or how will lose your taste for them,” says adding nuts or seeds to a salad – Yale University’s David Katz, things that require more chewing M.D., M.P.H. – draws out the meal. PROOF APPROVED CHANGES NEEDED And if it’s sodium you crave, try a splash of vinegar – which the PUT ON MOOD MUSIC CLIENT SIGN–OFF: pores in our tongue react to in the Last but not least, even sound can same way they do to salt. THAT It won’t impact how youARE perceive foods. An PLEASE CONFIRM THE FOLLOWING CORRECT taste exactly the same, but your Oxford University study showed

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that when 20 men and women ate toffee while listening to a brassy soundtrack, they perceived it as more bitter than when they ate the same toffee to tinkling piano music. Be mindful of a constant, unpleasant background noise. “You know how food often tastes bland on an airplane?” explains lead researcher Ann-Sylvie Crisinel, Ph.D. “Part of the reason is that the low-level noise of the engines has a masking effect on flavor.”

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OUT OF THE OR RECIPE

BY DIANE ROSSEN WORTHINGTON, TRIBUNE CONTENT AGENCY, ENTRÃ&#x2030;E

INGREDIENTS Serves 4 4 pork chops w ith bone on, about 1 1/2 inches thick, each about 1/2 pound Salt and black pepper 3 tablespoons olive oil 1 medium red onion, cut into eighths 1 16-ounce jar sweet cherry peppers, drained and the juice reserved 4 garlic cloves, minced 1 sprig of thyme 1 cup chicken stock 1/2 cup reserved pepper juice

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RECIPE

PAN ROASTED PORK CHOPS

A WEEKNIGHT TREAT

hen I’m stumped for a last minute main course dish, I often fall back on pork chops. They are perfect for quick meals since they don’t take long to prepare.

Pork chops come from the loin portion of the pig and are available either boned or with the bone attached. I like the center cut rib chop with the bone attached because the bone adds more moisture to the meat when you cook it; it also looks pretty. Pork may be the other white meat, but sometimes it can be tasteless and dry. It has been bred to be very lean, which may be good for our waistlines but challenging for our taste buds. If you can find kurobuta pork chops, they are worth the extra price tag. Kurobuta (Japanese black hog) pork, bred from Berkshire stock, is prized for its dark meat and rich flavor. American kurobuta pork is lean, yet still has small, fine streaks of marbling that produce a sweet, tender and juicy result. You can usually find this variety at fine supermarkets or meat markets. For more information on kurobuta pork, visit www.snakeriverfarms.com or www.lobels.com. Be mindful as the chops cook, paying careful attention to cooking time and temperature to make sure that you have a moist juicy chop. While many suggest cooking pork to an interior temperature of 160 F, I have found that is a simply too high. The pork should be slightly pink WWW.ORTODAY.COM

and at 145 F for both optimum flavor and texture. Trichinella spiralis, a parasite found in pork that causes Trichinosis, dies at 137 F, so cooking past that temperature should assure you that your dish will be safe as well as delicious. Use a meat thermometer for accuracy. This dish is first grilled and then finished in the oven – pan roasted – to guarantee even cooking. Be sure to use a heavy pan that can withstand high heat in the oven. So easy and tasty, these pork chops use bottled sweet cherry peppers to give the dish its punched up flavor. The peppers are bright red and green cherry gems that are sweet, slightly tart and mildly spicy, grown in California and then bottled in liquid. Look for the Mezzetta brand at your market or at the Italian deli. Serve these chops with simple buttered noodles, spaetzle or mashed potatoes. A zinfandel or an Italian barbera would make a nice wine accompaniment to this rustic dish. Diane Rossen Worthington is an authority on new American cooking. She is the author of 18 cookbooks, including “Seriously Simple Parties,” and a James Beard Award-winning radio show host. You can contact her at www.seriouslysimple.com.

DIRECTIONS 1. Season the pork chops on both sides with salt and pepper. 2. Preheat the oven to 425 F. 3. In a heavy ovenproof 12-inch pan or cast iron skillet heat the oil on medium-high heat. Add the pork chops and sauté on each side for about 3 minutes or until nicely seared. Remove to a side dish. 4. Add the onion and the drained cherry peppers; sauté until the onions are translucent, about 4 to 5 minutes, stirring occasionally. Add the garlic and thyme and sauté another minute. Add the chicken stock and reserved pepper juice, and bring to a boil on high heat. Return the pork chops back into the pan along with any juices. 5. Using potholders to avoid burning yourself, place pan in the oven and roast for about 15 minutes or until the pork chops are slightly pink and almost cooked through. Place the pork chops on a platter and lightly cover. The chops will continue to cook another 5 degrees after you take them off the heat, so don’t overcook them. 6. Place the pan back on the stove on high and reduce the liquid for about 3 to 5 minutes or until slightly thickened. Spoon the sauce around the pork chops and serve immediately.

April 2017 | OR TODAY

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OUT OF THE OR PINBOARD

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The News and Photos That Caught Our Eye This Month

OR TODAY

CONTESTS • APRIL • ARE YOU IN THE KNOW?

4 TIPS FOR BETTER SLEEP It’s no secret sleep is critical to one’s overall health and well-being. Next time you’re ready to crawl into bed, apply these four tips to help get better sleep. HARNESS THE POWER OF LIGHT: Light plays a critical role in producing melatonin, the hormone that helps induce sleepiness and regulate your sleep/wake cycle. Setting the right ambiance in your living room or bedroom with warmer, sunset-like shades of white light when you are ready to unwind can help support melatonin production and promote better sleep. With this in mind, Philips Hue White Ambiance offers a “Relax” mode that delivers a warm, amber-toned light designed to help you unwind and prepare for an undisturbed sleep. The connected

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lighting system also has a “Nightlight” mode that delivers a dim level of amber-reddish light designed to help you navigate the room to care for a crying child or go to the bathroom with minimal disruption to your sleep cycle. KEEP A CONSISTENT SLEEP SCHEDULE: Oftentimes, we tend to sleep less during the work week and make up for it over the weekend. By constantly shifting our sleeping patterns, we subject ourselves to jet-lag-like symptoms. We are creatures of habit and establishing a consistent time to go to bed helps your body react in kind. PAY ATTENTION TO HOW YOU WAKE UP: Exposing yourself to bright daylight is just as critical for regulating your sleep cycle and supporting better sleep quality. Try to make sure you get

enough light in the first one or two hours after waking. Light that emits cooler blue tones can help you feel refreshed, be more alert and improve your mood.

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TONE DOWN THE USE OF TECHNOLOGY BEFORE BED: In order to prepare yourself for a good night’s sleep, you should try to avoid intense light with cooler blue tones, which suppresses melatonin production. Relax an hour or two before going to bed – tucking away your mobile phone, computer or tablet, which might cause stress or overstimulate you prior to bedtime, disrupting your ability to sleep. – Brandpoint

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A SAVORY SNACK BAR SOLA Snacks delivers for busy Americans who no longer have time for three sit-down meals every day. The company’s launch of Sola Bars introduces a blend of crunchy peanuts, seeds, spices, and herbs offering superior flavor and nutrient-dense ingredients through a patent-pending process that binds ingredients without the need for sugar. With wholesome ingredients that are commonly found in the pantries of most American kitchens and with only 1 gram of

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courses … a glass of wine. What’s more, Sola Bars can be enjoyed solo as a quick impromptu meal for individuals with on-the-go, active lifestyles. Sola Bars come in four varieties: Roasted Garlic with Sea Salt, Jalapeno, Chipotle, and Cinnamon. They’re sold as individual bars or in packs on www.solasnacks.com and Amazon.com.

“YOU CAN’T STOP THE WAVES, BUT YOU CAN LEARN TO SURF.” -JON KABAT-ZINN 4 UNDENIABLE REASONS TO TRAVEL IN 2017 Studies show planning a vacation is one the best parts of the travel experience. It can boost your mood for weeks leading up to the big trip. Here are four tips to make the trip perfect: GET AWAY TO DISCONNECT: When planning a vacation, select a location where you can truly disconnect from your job and home responsibilities. For example, with 60 miles of coastline open for relaxation and fun, Myrtle Beach, South Carolina, is an easy drive or flight from virtually anywhere in the United States. Learn more at VisitMyrtleBeach.com. GET AWAY TO RECONNECT: AAA reports two out of three people say quality time with loved

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ones is the most important part of a vacation. In addition to selecting a great location, strive to find comfortable and convenient accommodations. GET AWAY TO BUILD MEMORIES: A whopping 91 percent of people say their favorite memory is a vacation, according to Expedia. com research. To set the stage for massive memory-making, select a location with something for everyone. GET AWAY TO TRY SOMETHING NEW: Trying an activity you’ve never done before is guaranteed to give you and your family memories to last a lifetime. Do some research about the destination you’ve selected and sign up for activities in advance to ensure you get the most convenient times.

FAMILY FUN

Stop dreaming and start planning – that unused PTO is full of possibilities. Let these ideas guide you to the vacation of a lifetime. – Brandpoint

April 2017 | OR TODAY

INDEX AAAHC………………………………………………………… 39 AIV Inc.………………………………………………………… 18 American Ultraviolet………………………………… 19 Ansell……………………………………………………………… 4 ASCA…………………………………………………………… 48 Augustine Temperature Management…… 30 Belimed………………………………………………………… 29 C Change Surgical………………………………………… 9 Calzuro.com…………………………………………… 49,70 Clorox…………………………………………………………… 59 Cygnus Medical……………………………………… 24-26 D. A. Surgical………………………………………… 50-53 Encompass Group……………………………………… 70

Flagship Surgical, LLC……………………………… 48 GelPro………………………………………………………………17 Healthmark Industries Company, Inc.…… 77 Innovative Medical Products…………………… BC Innovative Research Lab Jet Medical……… 67 Electronics Inc…………………………………………… 69 Kaap Surgical Insturments………………………… 27 MAC Medical, Inc…………………………………………… 5 MD Technologies inc.………………………………… 65 Medi-Kid Co.………………………………………………… 76 MedWrench………………………………………………… 70 Mobile Instrument Service & Repair……… 10 Pacific Medical……………………………………………… 6

Palmero Health Care………………………………… 27 Paragon Services……………………………………………71 Polar Products…………………………………………… 69 Ruhof Corporation………………………………………2-3 Sealed Air………………………………………………… IBC SIPS Consults……………………………………………… 73 Soma……………………………………………………………… 18 STERIS Instrument Management Services…15 TBJ Incorporated………………………………………… 64 TRU-D…………………………………………………………… 23

Cygnus Medical……………………………………… 24-26 Encompass Group……………………………………… 70 Healthmark Industries Company, Inc.…… 77 Palmero Health Care………………………………… 27 Ruhof Corporation………………………………………2-3 Sealed Air………………………………………………… IBC SIPS Consults……………………………………………… 73 TBJ Incorporated………………………………………… 64 TRU-D…………………………………………………………… 23

Kaap Surgical Insturments………………………… 27 Medi-Kid Co.………………………………………………… 76

INSTRUMENT STORAGE/TRANSPORT Belimed………………………………………………………… 29 Cygnus Medical……………………………………… 24-26

RESPIRATORY Innovative Research Lab Jet Medical……… 67 Soma……………………………………………………………… 18

LIGHTING/VIDEO PRODUCTION STERIS Instrument Management Services………15

SAFETY GEAR Calzuro.com…………………………………………… 49,70 Flagship Surgical, LLC……………………………… 48 GelPro………………………………………………………………17 Healthmark Industries Company, Inc.…… 77

USOC Medical…………………………………………………… 38

CATEGORICAL ANESTHESIA Augustine Temperature Management…… 30 Innovative Research Lab Jet Medical……… 67 Paragon Services……………………………………………71 Soma……………………………………………………………… 18 ASSOCIATION AAAHC………………………………………………………… 39 ASCA…………………………………………………………… 48 C-ARM Soma……………………………………………………………… 18 CARDIAC PRODUCTS C Change Surgical………………………………………… 9 Jet Medical Electronics Inc……………………… 69 Kaap Surgical Insturments………………………… 27 CARTS/CABINETS Cygnus Medical……………………………………… 24-26 Flagship Surgical, LLC……………………………… 48 Healthmark Industries Company, Inc.…… 77 MAC Medical, Inc…………………………………………… 5 STERIS Instrument Management Services…… 15 TBJ Incorporated………………………………………… 64 CRITICAL CARE Innovative Research Lab Jet Medical……… 67 DISINFECTANTS American Ultraviolet………………………………… 19 Clorox…………………………………………………………… 59 Cygnus Medical……………………………………… 24-26 Palmero Health Care………………………………… 27 Ruhof Corporation………………………………………2-3 Sealed Air………………………………………………… IBC DISPOSABLES Kaap Surgical Insturments………………………… 27 ENDOSCOPY Clorox…………………………………………………………… 59 Cygnus Medical……………………………………… 24-26 Healthmark Industries Company, Inc.…… 77 Kaap Surgical Insturments………………………… 27 Mobile Instrument Service & Repair……… 10 Ruhof Corporation………………………………………2-3 STERIS Instrument Management Services…… 15 FALL PREVENTION Encompass Group……………………………………… 70

MONITORS Pacific Medical……………………………………………… 6 Soma……………………………………………………………… 18 USOC Medical……………………………………………… 38 ONLINE RESOURCE MedWrench………………………………………………… 70 OR TABLES/BOOMS/ACCESSORIES D. A. Surgical………………………………………… 50-53 Innovative Medical Products…………………… BC Soma……………………………………………………………… 18 STERIS Instrument Management Services…… 15 OTHER AIV Inc.………………………………………………………… 18 Ansell……………………………………………………………… 4 TRU-D…………………………………………………………… 23 OTHER: CRANIOFACIAL RECOVERY PRODUCTS Medi-Kid Co.………………………………………………… 76 OTHER: FLOOR MATS GelPro………………………………………………………………17 OTHER: PEDIATRICS Medi-Kid Co.………………………………………………… 76 OTHER: SINKS/REPROCESSING STATIONS TBJ Incorporated………………………………………… 64 PATIENT DATA MANAGEMENT MAC Medical, Inc…………………………………………… 5

FOOTWEAR Calzuro.com…………………………………………… 49,70

PATIENT MONITORING AIV Inc.………………………………………………………… 18 Jet Medical Electronics Inc……………………… 69 Pacific Medical……………………………………………… 6 USOC Medical……………………………………………… 38

GENERAL AIV Inc.………………………………………………………… 18

PATIENT WARMING Encompass Group……………………………………… 70

INFECTION CONTROL American Ultraviolet………………………………… 19 Belimed………………………………………………………… 29 Clorox…………………………………………………………… 59

POSITIONING PRODUCTS Cygnus Medical……………………………………… 24-26 D. A. Surgical………………………………………… 50-53 Innovative Medical Products…………………… BC

FLUID MANAGEMENT SOLUTION Flagship Surgical, LLC……………………………… 48

OR TODAY | April 2017

REPAIR SERVICES Cygnus Medical……………………………………… 24-26 Jet Medical Electronics Inc……………………… 69 Mobile Instrument Service & Repair……… 10 Pacific Medical……………………………………………… 6 Soma……………………………………………………………… 18

STERILIZATION American Ultraviolet………………………………… 19 Belimed………………………………………………………… 29 Cygnus Medical……………………………………… 24-26 Healthmark Industries Company, Inc.…… 77 TBJ Incorporated………………………………………… 64 SURGICAL Kaap Surgical Insturments………………………… 27 SIPS Consults……………………………………………… 73 Soma……………………………………………………………… 18 STERIS Instrument Management Services…15 SURGICAL INSTRUMENT/ACCESSORIES C Change Surgical………………………………………… 9 Cygnus Medical……………………………………… 24-26 Healthmark Industries Company, Inc.…… 77 Kaap Surgical Insturments………………………… 27 SURGICAL MAT SOLUTIONS Flagship Surgical, LLC……………………………… 48 TELEMETRY AIV Inc.………………………………………………………… 18 Pacific Medical……………………………………………… 6 USOC Medical……………………………………………… 38 TEMPERATURE MANAGEMENT Augustine Temperature Management…… 30 C Change Surgical………………………………………… 9 Encompass Group……………………………………… 70 MAC Medical, Inc…………………………………………… 5 Polar Products…………………………………………… 69 WARMERS Belimed………………………………………………………… 29 MAC Medical, Inc…………………………………………… 5 STERIS Instrument Management Services…… 15 WASTE MANAGEMENT Flagship Surgical, LLC……………………………… 48 MD Technologies inc.………………………………… 65 Sealed Air………………………………………………… IBC TBJ Incorporated……………………………………………… 64

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