OR Today - September 2017 by MD Publishing

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SPOTLIGHT ON

NUTRITION

CHRISTINA BOBCO PAGE 47

TAKE GOOD CARE NURSES • SURGICAL TECHS • NURSE MANAGERS

WHOLE GRAINS PAGE 54

SEPTEMBER 2017

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Emergency Preparedness

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Building and using your accreditation toolkit. SEPT 22â&#x20AC;&#x201C;23, WASHINGTON, DC

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OR TODAY | September 2017

CORPORATE PROFILE Key Surgical recently announced a merger with Interlock and Clinipak, two European market leaders that also focus on products for the OR and sterile processing/central service departments. The merger has created a global provider in sterile processing and OR supplies.

Emergency Preparedness

EMERGENCY PREPAREDNESS To help health care facilities make emergency preparations for natural and manmade disasters, the Centers for Medicare & Medicaid Services (CMS) published a final rule last fall establishing new emergency preparedness requirements for hospitals and ASCs.

SPOTLIGHT ON: CHRISTINA BOBCO Christina Bobco is the kind of student who excelled in high school without blinking an eye and graduated without any clear vision for her future. So after high school, she spent some time at Gloucester County College figuring it out. She seems to have made the right decision.

OR Today (Vol. 17, Issue #7) September 2017 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 30269-1530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530. For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. ÂŠ 2017

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September 2017 | OR TODAY

CONTENTS

departments

PUBLISHER

John M. Krieg | john@mdpublishing.com

VICE PRESIDENT

Kristin Leavoy | kristin@mdpublishing.com

EDITOR

John Wallace | jwallace@mdpublishing.com

ART DEPARTMENT

Jonathan Riley Jessica Laurain Kara Pelley

ACCOUNT EXECUTIVES

Jayme McKelvey | jayme@mdpublishing.com Lisa Gosser | lgosser@mdpublishing.com

ACCOUNTING Kim Callahan

54 INDUSTRY INSIGHTS 11 News & Notes 16 AAAHC Update

IN THE OR

WEB SERVICES Cindy Galindo Kathryn Keur

CIRCULATION Lisa Cover Laura Mullen Jena Mattison

WEBINARS Linda Hasluem

20 Suite Talk 23 Market Analysis 24 Product Focus 28 CE Article

OUT OF THE OR 50 Fitness 52 Health 54 Nutrition 56 Recipe 60 Pinboard 62 Index

OR TODAY | September 2017

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INDUSTRY INSIGHTS NEWS & NOTES

STAFF REPORT

Clorox Healthcare Announces New Product Enhancements At the Association for Professionals in Infection Control and Epidemiology (APIC) 2017 annual conference, Clorox Healthcare announced enhancements to two of its disinfectants. Reformulated Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectants and Clorox Healthcare Bleach Germicidal Wipes continue to offer the same powerful disinfection efficacy that hospitals trust, now with improved surface compatibility and visibly less residue. “At Clorox Healthcare we are constantly innovating, continuously working to improve our industryleading product portfolio to meet the evolving needs of the health care environment. We are committed to providing the efficacy, compatibility and aesthetics that health care facilities need to provide optimal patient care,” says Laurie Rabens, senior product managermarketing, Clorox Healthcare. “For years Clorox Healthcare has led the field with disinfectants that health care facilities trust for their broad efficacy, fast kill times and ease of use. Now we’ve optimized those products for an even better user and patient experience.” Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant WWW.ORTODAY.COM

Wipes and Sprays offer the fastest non-bleach disinfecting times available for over 40 microorganisms and are noncorrosive to hard and soft surfaces commonly found in health care facilities. They are formulated for superior patient and staff comfort with no harsh chemical fumes or odors. Clorox Healthcare Bleach Germicidal Wipes, which kill 58 microorganisms, including Clostridium difficile (C. difficile) spores, in three minutes or less, have been optimized for extended usage in health care facilities with improved surface compatibility and less residue compared with competitor bleach disinfectant wipes. These product enhancements build on a legacy of innovation in ready-to-use cleaner-disinfectants engineered to eliminate the need for tradeoffs between efficacy and surface compatibility. Clorox Healthcare offers a portfolio of EPA-registered surface cleaner-disinfectants, in addition to UV technology, to provide health care facilities with a comprehensive approach to environmental hygiene for HAI prevention. The company also offers Clorox Healthcare Compatible, a resource

that helps health care facilities identify cleaning and disinfecting solutions that are compatible with the surfaces most commonly found in health care settings and helps manufacturers ensure that their products align with essential infection prevention protocols. Through the Clorox Healthcare Compatible program, Clorox Healthcare works with medical equipment manufacturers to provide complementary screening of a broad platform of chemistries, surface compatibility expertise and access to a third-party lab for testing to help ensure health care facilities can feel confident the disinfecting products they use to reduce the risk of HAIs won’t damage surfaces and equipment, and equipment manufacturers can provide the best instructions for the maintenance, cleaning and care of their products. • September 2017 | OR TODAY

INDUSTRY INSIGHTS NEWS & NOTES

Nuvolo Closes $10 Million Series A Financing Nuvolo has announced $10 million in Series A funding. GE Ventures led the round with participation from seed round investors New Enterprise Associates (NEA) and ServiceNow Ventures. The financing will accelerate the company’s global expansion plans and substantially increase investments in innovation, sales and customer success. “Nuvolo is a disruptive technology that is delivering previously unachievable improvements in enterprise service management for our customers,” said Tom Stanford, CEO of Nuvolo. “We are leading the industry by transforming the way that organizations manage, track, maintain and measure their enterprise assets, work spaces, facilities and suppliers.” Built on ServiceNow, Nuvolo is a modern, cloud-based

platform that meets the highest standards for ease of use, security, availability and performance. Nuvolo’s growth is being driven by success in health care, life sciences and regulated manufacturing, with broader adoption across a broad range of industries for facilities EAM. According to Noah Lewis, managing director, GE Ventures, “Together with NEA and ServiceNow, we are thrilled to back Nuvolo’s fast growth as they continue to delight customers with mobile-first solutions and scale to be a leader in the multi-billion-dollar enterprise asset management market. Nuvolo’s ability to enable the health care industry to optimize operations and better manage costs is core to our investment strategy.” •

Masimo Announces CE Marking of rainbow Super Sensor Masimo has announced the CE marking of the rainbow Super DCImini sensor, a reusable spot-check sensor that features Masimo SET Measure-through Motion and Low Perfusion pulse oximetry and rainbow SET technology with multiple physiologic measurements – including, for the first time, the ability to measure total hemoblogin (SpHb), carboxyhemoglobin (SpCO), methemoglobin (SpMet), and arterial oxygen saturation (SpO2) using the same noninvasive reusable sensor. In 2016, Masimo introduced the rainbow DCI-mini sensor, enabling spot-check measurement of Next Generation SpHb and other parameters. Now, with the rainbow Super DCI-mini sensor, an expanded set of parameters can be measured using a single sensor: SpO2, pulse rate (PR), perfusion index (Pi), pleth variability index (PVi), SpHb, SpCO, and SpMet. The rainbow Super DCI-mini sensor can be used to spot-check all patients weighing 3 kg or more, further reducing the need for multiple sensor types; the sensor can be 12

OR TODAY | September 2017

applied to an adult finger, a pediatric finger, or an infant finger, thumb, or great toe. The sensor is small and lightweight, with a flexible cable to provide sensor stability and patient comfort during monitoring. Next Generation SpHb technology offers motion tolerance and a faster time to display SpHb results (in as few as 30 seconds). In addition, field performance has been enhanced in lower hemoglobin ranges. Next Generation SpHb is enabled when the Rad-67 Pulse CO-Oximeter and the DCI-mini or Super DCI-mini sensor are used together. SpCO monitoring may lead to the identification of elevated carbon monoxide levels that might otherwise go undetected in front-line settings, such as triage and emergency care. SpMet helps clinicians monitor for methemoglobin in care areas where the drugs that cause methemoglobinemia are most common, such as procedure labs and the operating room. Joe Kiani, founder and CEO of Masimo, said, “This is an exciting day for us and hopefully a great opportunity to

improve patient care. Since the invention of rainbow technology, we have been wanting our customers to be able to measure SpCO, SpMet, SpHb and SpO2 simultaneously. Now they can! In addition, we have been pursuing a spot-check sensor that fits all patients across the age spectrum. We believe the rainbow Super DCI-mini sensor will be especially valuable for use in triage and emergency care situations. We plan to introduce a continuous measurement version of the Super Sensor in the near future.” The rainbow Super DCI-mini sensor, Next Generation SpHb, and Rad-67 have not received FDA 510(k) clearance and are not available for sale in the United States. • WWW.ORTODAY.COM

NEWS & NOTES

Techstyles Adds New Colors to Facial Protection Line Techstyles, a division of Encompass Group LLC, has announced new colors to its made in the USA facial protection line. New colors add an extra touch of style to a line known for it’s segmentleading features that include a lightweight design and non-glare, fog-free eye protection. StyleShields comes in four new colors: royal purple, lime green, bright orange, bold blue, and original black. Splash Mask now comes in bold blue, as well as original black. Encompass contact info is imprinted on the facial protection for easy reordering, and updated packaging offers information on proper use. According to the Occupational Safety and Health Administration (OSHA), not wearing eye protection

is the primary cause of eye injury and infection transmission. “We are pleased to offer new packaging and colors in our eyewear protection line,” said Kelley Terrell, marketing director, Techstyles Nonwoven Product Lines. “Our facial protection line is made in the USA, and provides fluid protection, superior fit, exceptional value, and now, a touch of style. And while it’s difficult to completely prevent the generation of droplets in a health care setting, our line is designed to perform. All Techstyles facial protection products fit with our belief that every patient, resident, caregiver and family member should feel safe and comfortable in today’s health care environments. Our new colors not only improve your ‘look,’ they may help improve your mood, too!” •

New USB Charger Safe for Patient-Care Vicinities Tripp Lite has introduced a USB wall charger certified to UL 60601-1 standards. The company states that it is currently the only USB charger on the market fully compliant for use in patient-care vicinities. Compliance gives this new USB wall charger approval for use in patient-care vicinities in hospitals, clinics and other medical facilities. Approval is based on regulations established in the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code and the 2012 edition of the NFPA 99 Healthcare Facilities Code. Ideal for patient, visitor or staff use, this wall charger provides one USB Type-A port with 2.5A of power for fast, efficient charging of smartphones, tablets, MP3 players or USB devices used in health care applications. It is compact and can be installed in patient rooms, nursing stations and treatment rooms, or sold in hospital gift shops for visitor and patient use. WWW.ORTODAY.COM

This new solution joins a family of health care-focused products developed by Tripp Lite for use inside and outside of patient-care vicinities. The product line includes power strips, surge protectors, UPS systems and isolation transformers. Key Features of Tripp Lite’s New Medical-Grade USB Wall Charger • UL 60601-1 listed and compliant with regulations for use in patient-care vicinities of healthcare facilities • Protects against overheating, overcurrent and overcharging • Integrated mounting tab allows for optional permanent installation on an outlet wall plate for compliance and security • For 120V, 50/60 Hz AC input • 5.2V, 2.5A (13W) DC output “Most USB chargers are not safe for use in patient-care vicinities, and that is what sets this new solution apart,”

said Jim Folk, Tripp Lite’s Director of Healthcare Solutions. “Because this USB wall charger is tested and compliant to UL 60601-1, it offers the safety and protection needed in health care environments, both for compliance and for peace of mind.” • For information about Tripp Lite’s health care solutions, visit www.tripplite.com/ hospital-medical-grade-power-strips. September 2017 | OR TODAY

INDUSTRY INSIGHTS NEWS & NOTES

Nationwide Opportunities STAFF REPORT

•Tech Support

•Medical Imaging

•Management

•In-house

•Service Sales

TRIM 4.5”

•Biomedical

Adel-Lawrence Associates on Forbes •Field Support List •Instructions Adel-Lawrence Associates Inc., has been recognized by Forbes as one of America’s best professional recruiting firms. This list of the top 250 companies highlights the most successful recruiting firms within the staffing industry. “We are honored to be named in the Forbes list”, said Larry Radzely, president of Adel-Lawrence Associates. “Our commitment to providing excellent customer service to both the companies and the candidates we assist is one of the main reasons we were selected. There are thousands of recruiting firms in the U.S., all vying to assist companies to get talent in the door, and

Adel-Lawrence Assoc., Inc. CALL LARRY RADZELY we are pleased 866-252-5621 that we are being recognized

as one of the best.” Founded in 1988, Adel-Lawrence Associinfo@alajobs.com | www.adel-lawrence.com ates has been built based on ethics, integrity, responsive service and trust. •

Advanced Sterilization Products Receives FDA Clearance For Biological Indicator AD SIZE the risk of hospital sterilization (ASP) has received FDA clearance departments releasing instruments DEALER TECHNATION ORTODAY forMEDICAL its 30-minute Sterrad Velocity prior to BI confirmation,” said ASP 1/6 Page Vertical Biological Indicator (BI) System. Global Marketing Vice President GUIDE By BUYERS reducing the time it takesOTHER to get Amy Smith. “Now they will finally NOTES results, from several hours to 30 be able to know with certainty that MONTH minutes, this new enhancement to proper sterilization conditions the company’s complete sterilizahave been achieved before the intion ecosystem gives hospitals the struments are used in patients.” opportunity to raise their standard J F M A M J J A Earlier S this O year, N ASP D enhanced of care by running a BI in every its overall sterilization solution cycle, every day. with the full launch of STERRAD DESIGNER: JL Ensuring that all surgical deSystems with ALLClear Technolvices are properly sterilized is one ogy and ASP Access, a smart inforway health care workers can help mation sharing technology. Sterrad elevate patient safety while also reduce the incidences of health Velocity is the only BI reader that maximizing compliance and efficare-aquired infections (HAIs). BIs can automatically communicate BI ciency in their daily routine,” said help to prevent HAIs by providing information to STERRAD Systems, Smith. “Our complete ecosystem assurance that instruments used ITS and hospital networks, miniis designed to work together to on patients are sterilized. Hospital mizing the need for manual docuprovide the most accurate results. sterilization professionals will now mentation and reducing the potenThis ensures the lives of patients be able to deliver instruments to tial for human error. are better protected at a time the operating room faster and with “As the only company that ofwhen they are already vulnerable greater peace of mind. fers an integrated, end-to-end – when they are in hospitals and “With a significantly shorter sterilization solution, ASP is in a undergoing potentially life-changwait time, Sterrad Velocity reduces unique position to help customers ing procedures.” Advanced Sterilization Products PUBLICATION

OR TODAY | September 2017

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INDUSTRY INSIGHTS AAAHC UPDATE

BY ANGELA FITZSIMMONS

AAAHC UPDATE

THE MYTH OF THE PERFECT SCORE

AAHC strives to educate ambulatory health care facilities about the value of measuring and improving the quality of their services. We are already very serious about providing the best quality service that we possibly can – hence our getting a perfect score twice on the accreditation test.

ties to consider. Many of these options build messages that also can translate to images for social channels. Figuring out how to promote your accreditation can continue the team building that has gone into preparing for a survey. GETTING CREATIVE

I like everything about this message. Except the last seven words. Accreditation is not a test and organizations do not end up with a score. I know what was meant (and so do you): based on the survey report that came with the decision letter, there were no Standards (or elements of Standards) rated partially- or non-compliant. In other words, the survey team found no evidence of significant deficiencies and all applicable Standards were rated “substantially compliant.” MARKETING YOUR SUCCESSFUL ACCREDITATION

Part of my job as marketing and communications director is to monitor mentions of AAAHC that appear online and in print. As a leading accrediting organization, AAAHC provides articles (like this one), as well as expert opinion in response to many health care issues that affect ambula16

OR TODAY | September 2017

tory settings. When a mention is the result of direct outreach – ours or that of a reporter – we are usually aware of when and where it will run. Occasionally, I will be surprised by a non-accredited organization making a false claim of accreditation and those discoveries are shared with our legal department. More frequent, however, are announcements made by organizations that have received a positive decision following a successful accreditation or reaccreditation survey. They share the good news as a means of celebrating the hard work of their staff and providers, and to showcase to a broader audience the quality of the health care services they provide. Marketing your accreditation is a good idea – we help by providing “accredited by AAAHC” logos for print and digital uses, a template for a basic press release, and a list of other activi-

Some organizations have gone above and beyond in creativity. I know of one ASC that has replaced “hold music” in their phone system with an explanation of what accreditation means for patients. I’ve seen videos posted to websites touting the contributions of each department of an ASC. The clearly celebratory tone and the many Facebook posts with smiling staff showing off a newly received certificate of accreditation do a lot to communicate the sense of achievement. But sometimes, an organization will strike a discordant note (at least to my ears) with something that sounds like: XYZ Clinics received an exceptional score of 100 percent in a reaccreditation survey… Michael Huey, M.D., Executive Director, Student Health and Counseling Services, Emory University and a AAAHC surveyor for over a decade says, “the only thing worse than a failWWW.ORTODAY.COM

AAAHC UPDATE

ing survey is a ‘perfect survey,’ because a perfect survey doesn’t give you any place to go to improve.” A “test” that receives an “A” will never be looked at again. It’s the opportunities for correction that get attention.

YOU HAVE QUESTIONS.

WE HAVE ANSWERS!

CHANGES TO RATINGS FOR 2018

The next edition of the “Accreditation Handbook for Ambulatory Health Care” is scheduled to be released in September. The biggest change that AAAHC-accredited organizations will notice is the introduction of “elements of compliance.” The Standards continue to be written as broad-based statements. The elements of compliance will be the indicators that a surveyor will look for to demonstrate compliance and each will be assessed as yes/no. Then, the number of yes responses will be counted and applied to a rating chart for each Standard that will range from “fully-“ to “non-compliant.” For those who look for that “perfect score,” the new rating methodology could, in fact, result in a survey that reflected full compliance with AAAHC Standards. Still, rather than marketing the message, “we got an A,” I’d prefer to see a story that says, “we’re an organization interested in continuous improvement. That is why we invite an independent thirdparty to review our policies and procedures against nationally recognized standards. With each triennial survey, we strive to improve our organizational and clinical operations. Our ongoing accreditation tells us we’re serving our patients well. Come see for yourself.” Ms. FitzSimmons is responsible for AAAHC publications. Her team focuses on bringing best practices to life by sharing concepts addressed via AAAHC Standards and by highlighting excellence as exemplified by AAAHC-accredited organizations, surveyors and staff. WWW.ORTODAY.COM

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INDUSTRY INSIGHTS ASCA UPDATE

BY WILLIAM PRENTICE, ASCA CHIEF EXECUTIVE OFFICER

ASCs MOVE FORWARD IN 2017

s we head into the final months of 2017, ASCA and members of the ASC community have already covered a lot of ground this year when it comes to the work we need to do to reach key decision makers who can help protect patient access to ASCs and the cost-efficient, top-quality care that ASCs provide. ASCs are now represented in more high-level policy discussions than ever before and helping to define policies for the future that will serve the best interests of patients who need outpatient surgical care.

NATIONAL ADVOCACY DAY

At ASCA’s annual meeting in Washington, D.C., this May, more than 300 ASCA members visited their members of Congress on Capitol Hill. During those visits, ASCA’s members asked their elected officials to support ASCs by cosponsoring the Ambulatory Surgical Center Quality and Access Act of 2017 (H.R. 1838/S. 1001). This bill would change the Medicare inflationary update factor that contributes to the growing disparity between ASC and hospital outpatient department (HOPD) payments. Thanks to these constituent meetings and other outreach efforts regarding this bill that ASCA conducted this year, as this magazine goes to print, the legislation now has 50 cosponsors in the House and six in the Senate. You can learn more about that bill at www. ascassociation.org/asc-qaa-2017. ASCA MEETS WITH HHS SECRETARY PRICE AND CMS ADMINISTRATOR VERMA

During June, ASCA was part of a roundtable discussion with U.S. Depart18

OR TODAY | September 2017

ment of Health & Human Services (HHS) Secretary Tom Price, M.D., and Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma. Others at the meeting represented physician groups focused on specialties including anesthesia, orthopedics, ophthalmology and more. The session was designed to allow those involved to identify specific regulatory burdens that HHS could eliminate. Each organization present was given three minutes to present, and ASCA used that time to discuss Medicare’s ASC payment system and the procedures that ASCs are allowed to perform for the program’s beneficiaries. First, ASCA pointed out that since ASC payments are tied to the HOPD payment system and both ASCs and HOPDs face the same increases in the cost of doing business each year (e.g., equipment, devices, implants, facility upkeep and staffing costs), ASC payment updates each year should be based on the same update factor as the hospitals. To accomplish that goal, ASCA recommended that CMS replace the Consumer Price Index for

All Urban Consumers (CPI-U) with the hospital market basket as the update mechanism for ASC payments. Second, ASCA asked CMS to begin reimbursing ASCs for all of the same surgical codes for which it reimburses HOPDs. At a minimum, ASCA asked CMS to add the codes recommended by industry clinicians. In conjunction with that meeting, ASCA also submitted a form that identified nine areas where ASCs and ASC physicians are seeking relief. That document suggests changes in areas ranging from the definitions surrounding device-intensive procedures, the way the new Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery (OAS CAHPS) survey is administered and compliance with the new Life Safety Code requirements. NEW PAYMENT MODELS

Back in March, ASCA representatives met with staff from the Center for Medicare & Medicaid Innovation (the Innovation Center). The Innovation Center, with CMS, supports the development and testing of innovative health care payment and service delivery models. At this meeting, ASCA member Scott Leggett gave a presentation on a bundled payment model in the ASC setting. Leggett is the chief executive officer of Surgery One, LLC, which co-manages four outpatient surgery centers located in San Diego County, California. The “ask” in this meeting was for the Innovation Center to consider a bundled payment model pilot program for total joint replacements performed in the ASC setting. WWW.ORTODAY.COM

ASCA UPDATE

We expect that this meeting was just the first step in what could be a long process but found genuine interest in the proposal from the Innovation Center staff. PATIENT SAFETY AND FACILITY DESIGN

In June, the Facility Guidelines Institute (FGI) announced the appointment of David M. Shapiro, M.D., to its board of directors. Shapiro is an anesthesiologist with extensive experience in ASC management and a past-president of ASCA. Among his many credentials, he is a Certified Administrator Surgery Center (CASC), a Certified Professional in Healthcare Risk Management (CPHRM) and certified in Health Care Quality Management. Shapiro joined FGI’s Health Guidelines Revision Committee (HGRC) Outpatient Document Group during the 2018 Guidelines for Design and Construction revision cycle to represent the ambulatory surgery industry. The insight and guidance he provided there were of great importance to the HGRC as it endeavored to separate hospital and outpatient requirements into two separate documents to better meet the disparate and evolving needs of outpatient facilities. ELECTRONIC HEALTH RECORD USE REQUIREMENTS AND PUBLIC DATA REPORTING

Also during June, ASCA submitted formal comments in response to the 2018 Inpatient Prospective Payment System (IPPS) proposed rule that CMS released in April. Provisions addressed in those comments relate to the required use of electronic health record technology by ASCbased physicians and the public release of data revealed in ASC accreditation surveys. The 21st Century Cures Act enacted last year exempts ASCWWW.ORTODAY.COM

based eligible professionals (EP), or certain physicians who furnish substantially all of their covered professional services in an ASC, from payment cuts in 2017 and 2018. CMS proposed two possible definitions for an ASC-based EP. One, which matches a comparable hospital definition, defines “substantially all” as 75 percent or more of the covered services. The second option sets that figure at 90 percent. ASCA supported the lower 75 percent threshold, consistent with the hospital-based EP threshold, and recommended CMS finalize this as part of the ASC-based EP definition in the final rule. The larger issue for EPs who practice in ASCs, however, has been CMS’ interpretation that ASC encounters are currently being included in the denominator when determining whether an EP is a “meaningful user” of CEHRT. Given that no CEHRT exists for the ASC setting, this means that EPs who have more than 50 percent of their outpatient encounters in an ASC could face payment reductions. This impacts a much greater number of eligible providers, and since there is currently no CEHRT for ASCs, ASCA asked CMS to clarify that these encounters should not be counted in the denominator of any calculations that determine adequate use of CEHRT products. On the accreditation front, CMS is proposing to require accrediting organizations with CMS-approved accreditation programs to post final accreditation survey reports and acceptable plans of correction (PoCs) on a public-facing website. Because access to meaningful data, rather than simply a large volume of data, is what provides real value to patients, ASCA recommended that CMS withdraw its current proposal. Instead, ASCA recommended that CMS bring together accreditation organizations, providers and suppli-

ers, information technology experts, consumer research groups and others with expert knowledge of access to data available in the health care industry to assist CMS with identifying and developing opportunities for providing consumers with the appropriate data to support transparency and decision making. SURVEY & CERTIFICATION AND CLINICAL STANDARDS STAFF

In yet another June meeting, ASCA president Rebecca Craig, RN, MBA, CNOR, CPC-H, CASC, met with ASCA staff and representatives from the Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group and Clinical Standards Group. Takeaways from this meeting included: • CMS’ commitment that Appendix L of the State Operations Manual, which ASCs often use to assess their compliance policies and prepare for surveys, will be updated to reflect new regulatory language related to implementation of the revised emergency preparedness requirements; • CMS’ confirmation that language currently included in the State Operations Manual: Appendix L is not meant to preclude ASCs from having electronic health records; and • CMS’s agreement that it would take under advisement concerns that ASCA raised about purely competitive reasons that can drive a hospital’s decision to refuse to enter into a transfer agreement with an ASC. Much work remains, and ASCA and its members are continuing to work in all of these areas and others. I encourage everyone who works in or with an ASC to participate. If you would like to learn more about how to get involved, please contact Danielle Kaster at dkaster@ascassociation.org. September 2017 | OR TODAY

IN THE OR SUITE TALK

STAFF REPORT

SUITE TALK

Conversations from the OR Nation’s Listserv

WATER IN PANS When instruments are removed from the autoclave and not given an adequate time to cool down sometimes condensation can form inside the instrument pans. Is it considered contaminated if a pan has water in the bottom tray, but has met all the sterilization parameters? A: I remember the various container reps at A: Yes. this years AORN conference in Boston said “Yes.” A: Yes, it is considered contaminated if any condensation is either on the packaging or A: Yes it is. inside the tray. It must be dry to be considered sterile.

CODE BLUE IN OR What is the protocol at your facility regarding calling a code blue in the OR? Is the code paged overhead and/or a hospital code team notified or is the code handled internally by OR personnel? We are working to clarify our policy for non-OR personnel who currently respond to code blues in the OR. Confusion arises when they show up and aren’t sure of whether they should enter the OR, put on a bunny suit, etc. If anyone has a policy specific to these questions and is willing to share I would greatly appreciate it. A: Our OR team only handles OR codes. A: We handle all our own codes in the OR until late in the evening or when on call. That

is when we ask them to overhead page for assistance due to limited staffing. We have the bunny suits, hats and shoe covers readily available in the entrance.

DE-STRESS TIPS NEEDED Being a nurse is stressful. We all know that! But how do you de-stress? A: Remember to take care of yourself. These tips are basic, but important. Get a good night’s sleep and have a routine for relaxing before bed, eat healthy, exercise and spend time with family and friends when you are off. A: Walk to the pond and feed the ducks. A: Go outside for lunch and disconnect from 20

OR TODAY | September 2017

technology (even Facebook). Do meditative breathing and focus on nature and the sound of birds. A: That’s a very good idea. A: I got this from an article some time ago and keep it on my bulletin board.

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SUITE TALK

7 WAYS TO COMBAT BURNOUT 1) Recognize Burnout: Feeling underappreciated Unclear job demands Too many projects Not enough sleep Lack of close relationships High-achieving Type A a personalities The need to control everything A pessimistic view of themselves

2) P romote emotional and physical health (eat right, sleep and exercise) 3) C reate a positive work environment and open door policy 4) Address staffing concerns immediately 5) Take regular breaks

6) Disconnect from technology for 10-15 minutes and do meditative breathing. If you can’t get out of the office, close your office door and put up a sign saying you will return in 15 minutes 7) Seek out support, have an outlet to channel your thoughts, feelings and emotions (employee assistance programs to vent confidentially to a counselor)

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

PRESSURE ULCERS FUEL WOUND CARE MARKET

he global wound care market is expected to reach $20.4 billion by 2021 from $17.0 billion in 2016, growing at a compound annual growth rate of 3.6 percent from 2016 to 2021, according to a report from MarketsandMarkets. “Diabetic foot ulcers and pressure ulcers are types of chronic wounds, affecting millions of people around the world. The prevalence of diabetes is rising at a high rate, and various studies and statistics state that around 15 percent of people suffering from diabetes are at a risk of diabetic foot ulcers, once in their lifetime,” according to a PRNewswire news release. “Also 24 percent of diabetic foot ulcers usually progress to a stage requiring amputation of the leg/foot. Pressure ulcers are most common cause of hospitalization and longer hospital stays, reducing the mobility of the patients. Incidences of hospital-acquired pressure ulcers, and medical devices-acquired pressure ulcers are increasing at an alarming rate.” “These factors in combination with other factors such as increasing prevalence of chronic diseases, such as cancer, HIV, peripheral artery and vascular diseases, rising percentage of geriatric population, obesity and other conditions, are responsible for the high growth of the global diabetic foot ulcers and pressure ulcers market in 2015,” according to PRNewswire. WWW.ORTODAY.COM

“The global pressure relief devices market is expected to reach $4.1 billion by 2025,” according to a new study by Grand View Research Inc.

“ Geriatric population is prone to developing bedsores due to impaired mobility. Similarly, obese patients are at higher risk of ulcer development as they are required to stay in hospitals for prolonged periods.” “The rapidly growing number of elderly population worldwide and rising awareness about pressure ulcers through campaigns along with the increasing base of obese population are expected to drive the industry growth.” “The incidence of pressure ulcer development has been rising since the past few years in hospital set-

tings. According to a 2013 study by the Centers for Medicare and Medicaid Services (CMS), health care expenditure on hospital-acquired illnesses, including bedsores, has increased at a rate of 7 percent from 2000 to 2013,” Grand View Research Inc. reports. As baby boomers age, more and more of the U.S. population becomes prone to acquiring a pressure ulcer. A high-rate of obesity is another indicator for the pressure ulcer wound care market. “Geriatric population is prone to developing bedsores due to impaired mobility. Similarly, obese patients are at higher risk of ulcer development as they are required to stay in hospitals for prolonged periods. The limited mobility amongst these target populations will drive growth in this industry,” according to Grand View Research Inc. “Creating awareness about pressure ulcer development is crucial since they are avoidable with proper precautions. Various campaigns such as ‘Stop the Pressure’ have been arranged by governments to spread the awareness about pressure relief amongst patients and care providers,” according to Grand View Research Inc. “More than 2.5 million people in the U.S. and 0.7 million people in UK are affected by pressure ulcers every year.” September 2017 | OR TODAY

IN THE OR PRODUCT FOCUS

ACELITY V.A.C. VERAFLO CLEANSE CHOICE™ DRESSING The Acelity V.A.C. VERAFLO CLEANSE CHOICE™ Dressing, when used with V.A.C. VERAFLO™ Therapy, can be used to initiate immediate wound cleansing therapy and facilitate removal of wound exudates and infectious materials. The dressing’s unique three-layer design provides “mechanical” movement at the wound surface in combination with cyclic delivery and dwell of topical solutions facilitating softening and removal of thick exudate material, such as fibrin, slough, and other infectious material, providing a wound cleansing option for clinicians when surgical debridement must be delayed or is not possible or appropriate. The V.A.C.ULTA™ Negative Pressure Wound Therapy System, with and without instillation, is indicated for patients with chronic, acute, traumatic, sub-acute and dehisced wounds, partial-thickness burns, ulcers (such as diabetic, pressure, and venous insufficiency). •

OR TODAY | September 2017

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PRODUCT FOCUS

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September 2017 | OR TODAY

IN THE OR PRODUCT FOCUS

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OR TODAY | September 2017

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OR TODAY | September 2017

BY GUY H. HASKELL, PHD, JD, NREMT-P; JEANNE SEELYE, MSN, RN, CEN; AND JEFF SOLHEIM, MSN, RN-BC, CEN, CFRN, FAEN

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CONTINUING EDUCATION CE681B

WHEN DISASTERS STRIKE: PREPARING FOR THE UNEXPECTED

ony checks all the equipment on his rig and in his pack, a task that he and every paramedic he works with complete at the beginning of each shift. Today is starting out like any other day at the ambulance station.

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

Goal and objectives The goal of this program is to inform RNs and EMTs about the types of disasters and the interventions for preparing to help with response to disasters. After studying the information presented here, you will be able to: • Explain the four stages of disaster management • Correctly triage a patient using disaster triage criteria • Describe unique considerations when the disaster involves a chemical, radio

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Sara, an RN, listens intently to report from the off-going night shift nurse. “Two ICU holds,” Sara mumbles under her breath. “Looks like another typical day here in the ED.” But today will be anything but typical. At 11 a.m., a disgruntled ex-boyfriend walks into a church less than one mile from both the ambulance station and the hospital, opening fire in the midst of a wedding ceremony. In less than 10 minutes, bullets are imbedded in the bodies of not only the bride and groom, but five of their wedding party and 31 of their guests. The gunman then turns the gun on himself. Triage will reveal that of the 39 victims, eight have suffered fatal wounds; 17 are severely injured and will require immediate transport, stabilization, and operative intervention; and the remaining 14 have suffered less catastrophic wounds but will require transport and treatment. All available off-duty personnel are called in to help with the disaster, and mutual aid from three neighboring communities is used. The large number of patients, coupled with the severity of injuries, strains the resources of the community healthcare system to capacity. But thanks to a well thought-out and rehearsed disaster plan, staff can

respond appropriately, and the loss of life is minimized. TYPES OF DISASTERS

This fictional scenario represents a manmade disaster, which is an incident that arises from human involvement. Other examples of manmade disasters include motor vehicle collisions involving multiple victims, explosions, the release of toxic chemicals, and structural collapses involving buildings, bridges, or mines.1,2 Sometimes the disaster does not include human involvement. A hurricane, for example, arises directly from the forces of nature. Other examples of natural disasters include tornados, floods, and earthquakes.1,2 Manmade and natural disasters have something in common: They may strain community and institutional resources. Another way to define a disaster is the degree to which those resources are strained. •M ultiple-patient incident (sometimes called a level-1 disaster): This type of incident would likely be handled by local emergency response personnel and organizations without outside resources. While it might create a difficult shift, it September 2017 | OR TODAY

IN THE OR CONTINUING EDUCATION CE681B would likely not spill over into subsequent shifts.1 •M ultiple-casualty incident (a level-2 disaster): This type of incident would likely require regional efforts and mutual aid, and involve multiple facilities. The effects would have an impact on staff from shift to shift at locales.1 •M ass-casualty incident (a level-3 disaster): This type of incident will require a coordinated effort not only by multiple facilities, but also by multiple agencies and, possibly, multiple communities. Frequently, state and federal resources are required.1 STAGES OF EMERGENCY MANAGEMENT

And no matter the type or size of the disaster, the four stages of emergency management used to prepare for and respond to the incident are identical: mitigation, preparedness, response, and recovery.1 The initial stage of emergency management, mitigation, prepares an institution to reduce the risk of a disaster by identifying likely threats and determining ways to minimize the effect of those threats. The identification of threats is called a hazard vulnerability analysis (HVA).3 A hospital along the coast in Florida, for example, would likely recognize that it has a likelihood of experiencing the effects of a hurricane. Therefore, considerable time and resources should be invested into preparing for the effects of that form of disaster. It would be a waste of time for a hospital in the Midwest to invest time and resources in hurricane preparedness, but an HVA may uncover that trains frequently traverse the community carrying toxic chemicals that could lead to an equally catastrophic disaster. Therefore, the hospital in the Midwest will 30

OR TODAY | September 2017

likely put time and resources into preparing for a chemical spill. Once the HVA is carried out and potential threats are uncovered, mitigation continues. The institution determines what things it may do to reduce the risks uncovered during the HVA. If the HVA reveals potential danger from hurricanes, for example, the facility may elect to modify the building by applying shutters to windows since shutters can reduce flying debris inside a building caused by high winds. Mitigation helps an organization direct limited resources to the areas in which it is most vulnerable. The second step in disaster planning is preparedness. Despite a thorough HVA and appropriate building modifications, a disaster can still harm an institution. Preparedness helps to minimize the negative impacts. Using the example of the hospital in Florida, despite adding shutters to the windows, an unusually strong hurricane could still cause damage to the physical plant. Furthermore, even if the facility survives the hurricane relatively unscathed, downed trees and flooding may restrict the ability of staff to respond after the hurricane to render assistance. Preparedness is the step in which each of these eventualities is considered and plans are put into play to minimize these negative impacts. Preparedness allows the facility to continue to offer patient care despite shortcomings that arise from a disaster. Components of the stage of preparedness include: • Developing disaster plans and then providing training to staff on those plans as well as regularly holding drills to test the disaster plan. Plans may be revised based on things learned during the drills. • Securing contracts with government and nongovernment agen-

cies to provide mutual aid • Securing mutual aid agreements with transport agencies and other surrounding facilities. If the number of patients exceeds the hospital’s ability to care for those patients or if the institution is damaged beyond the capability of continuing services, the mutual aid agreements allow the facility to rapidly distribute the workload throughout the community. • Stockpiling supplies in the case the hospital is isolated from the outside world for a time The third stage of disaster management is the response stage. It begins when authorities are aware that a disaster is going to happen (e.g., this area will flood in the next 72 hours) or it has already happened (e.g., there has been a pile-up on the freeway with multiple casualties). The response stage involves putting the plans designed during the preparedness phase into action. The response stage will be described in further detail in the following paragraphs. The final stage of disaster management is the recovery phase. This begins when the response stage ends and brings the institution and community back to its normal level of functioning. The recovery phase may include activities such as imbedding disaster charts into regular inpatient charts, repairing the physical plant, and caring for the physical and emotional needs of the personnel involved in the disaster response. Another integral aspect of the recovery phase is evaluating what occurred in the response phase to determine if things should be altered in preparation for a similar event. Did the disaster plan work as it was supposed to? If not, how can it be changed to be more effective? Did the agreements and contracts that were put into play before the disaster provide the assistance needed? If not, how can those be strengthened or replaced?3 WWW.ORTODAY.COM

CONTINUING EDUCATION CE681B

Based on what is found in each of these categories, patients are assigned a disaster triage priority level. Each category in the disaster triage system is color coded as follows:4 • Green (minor) is the easiest category to define. This categorization includes all patients who can get up and walk to a designated treatment area upon request. • Yellow (delayed) includes all victims who have injuries that can be serious or potentially lifethreatening but whose status is not expected to decline if transport is delayed, even for hours. • Red (immediate) is reserved for patients in need of immediate life- or limb-saving intervention. Patients assigned a red triage priority can be helped if immediate intervention and transport are rendered. • Black (deceased) is a level asSTART Triage Diagram signed to patients unlikely to survive given the severity of their injuries. The START triage system allows rapid sorting of multiple patients with minimal resources. The tool JumpSTART provides an objective framework for triaging children in a mass casualty incident. The objectives are to optimize the primary triage of injured children, enhance the effectiveness of resources, and reduce the emotional burden on personnel who may have to make a life or death decision about a child in a chaotic situation.4 The principle is the same as with adults, but the physiological differences of a child are taken into consideration. Minor victims are screened to a secondary triage area if they can walk. Victims who cannot walk are screened based on respiratory rate, palpable pulse, level of Source: Courtesy Christopher A. Kahn, MD, MPH. Copyalertness, response to verbal and right © 2009 American College of Emergency Physicians. painful stimuli, and unresponsivePublished by Mosby Inc. All rights reserved.

DISASTER TRIAGE

One part of a disaster response is disaster triage, the process of sorting the injured based on their likely benefit from immediate medical treatment.4 The triage system most widely used is the Simple Treatment and Rapid Triage system.5 With START, personnel prioritize patients into one of four categories based on the following factors:4 • Ability to get up and walk away • Respiratory rate: Is it less than or greater than 30? • Pulse: Is a radial pulse palpable? • Is capillary refill greater than or less than two seconds? • The patient’s ability to follow simple commands, in other words, his or her mental status A mnemonic useful for remembering rapid triage is RPM: respirations, pulse, and mental status.

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ness, also known as the AVPU (alert, voice, pain, unresponsive) scale. The biggest difference between pediatric and adult disaster triage is the performance of rescue breathing. Based on START triage, if an adult is found apneic, a single attempt is made to open the airway. If spontaneous respirations do not return, the patient is assigned a triage categorization of black. When using JumpSTART triage, if a child is apneic but has a palpable pulse, the airway is opened and one attempt at five rescue breaths is made. The return of spontaneous respirations places the child in the immediate category. A respiratory rate of less than 15 or greater than 45 also results in placement in the immediate category. To be considered for the delayed category, a child must have a respiratory rate between 15 and 45, a pulse, and a mental status that is appropriate in the categories of alert, response to painful or verbal stimulus.4 PREHOSPITAL CONSIDERATIONS

Disaster response preparation and training has become an integral and ongoing process in most EMS systems. The standardization of the national Incident Command System (ICS) has provided a template for responders throughout the country. From EMTs to EMS chief, most jurisdictions require personnel to take ICS training.6 The ICS has been designed to be flexible, so the role of the EMS in the ICS is determined by the type of incident, the resources available, and local practices and agreements. In any disaster, communication through a structured command system is crucial to an effective response. (Full implementation of ICS is required rarely, in major incidents, but partial implementation is appropriate on almost every call.) The ICS was included as a part of the National Incident ManageSeptember 2017 | OR TODAY

IN THE OR CONTINUING EDUCATION CE681B ment System (NIMS) by the Federal Emergency Management Agency’s program to standardize disaster preparation, management, and training through its National Response Framework. The ICS gives the emergency responder an organized system to manage mass casualty incidents effectively. The six stages of incident command are preplanning and training, initial response, operations, stabilization, demobilization, and termination.7 Cooperation and communication between public safety agencies, transportation agencies, and the healthcare industry through a structured command system is essential to effective disaster response, and efforts are ongoing to improve cooperation and communication. JumpSTART Pediatric MCI© *Evaluate infants first in secondary triage using the entire JS algorithm

Source: Copyright © Lou Romig, MD. You may then use these materials for your own agencies and colleagues as long as they are used solely for educational and protocol/policy purposes and no substantive changes are made. You can reach Romig directly by writing to louromig@bellsouth.net.

OR TODAY | September 2017

Each jurisdiction establishes its own operational plan, but certain aspects of the EMS response are universal. In most jurisdictions, the fire department assumes overall command authority although in some areas the police department has that role. It is rare for the EMS to assume the overall role of incident command, usually because this branch is smaller with fewer resources.8 Nevertheless, the first unit on the scene, regardless of department, establishes incident command until relieved. The key to effective use of the ICS is adapting it to the particular response and local conditions and resources. The ICS is designed to be flexible; therefore, the role of EMS in the ICS is determined by the type of incident, the resources available for that incident, and local practices and agreements. Providing EMS during a mass casualty incident requires effective command, communication, triage, treatment, staging, and transportation. The larger the incident, the more formal the structure required; the smaller the incident, the more flexible the structure.9 The ICS is now used in many departments on almost every call. This not only ensures a command structure for the incident, it also trains crews in the system and gets them used to using it in their daily practice. A call is received for an “asthma attack” at 234 Main St. Engine 1 and Medic 1 dispatched. Engine 1 arrives first on scene and radios, “Engine 1 assuming Main Street command, one-story home, one patient. EMS not yet on scene, investigating.” Now dispatch, Medic 1, and anyone else in the system listening knows who, what, and where to report if necessary. For most incidents, EMS will be assigned primarily to the operations section. EMS will usually be

involved with setting up staging areas and running triage. Personnel and equipment may be attached to various strike teams and task forces depending on the incident. EMS will also be involved in the logistics section, ensuring communications with its resources, providing medical supplies and, of course, organizing transportation from the scene and distributing patients appropriately to healthcare facilities.10 In a disaster involving mass casualties, the appropriate EMS officer will usually be located with the overall incident commander. If disparate locations are involved, site command may be established remotely. Patient transport is, of course, one of the primary duties of EMS. In a large incident, local resources may be inadequate to handle the load, and contingency plans must be made: mutual aid agreements with surrounding services, using alternative means of transportation, such as buses or private vehicles where appropriate and necessary. Appropriate disaster planning will help prepare for this eventuality. A transportation unit must be established in conjunction with the appropriate staging areas to allow transport vehicles access and egress from the scene without interfering with other aspects of the response.11 If an emergency involves several family members, try to keep them together if the nature of their injuries makes that possible. INSTITUTIONAL RESPONSE

The healthcare facility’s response focuses on increasing its capacity and capability to care for victims of an emergency. In the ED, communication is crucial to the effective management of a response to disaster. The Hospital Incident Command System is designed to collaborate with EMS and be consistent with NIMS.12 The goal is to encourage WWW.ORTODAY.COM

CONTINUING EDUCATION CE681B

coordination between the facility’s and community’s responses to the emergency, grouping services into more easily manageable sections. In multiple patient scenarios, many patients will be walking wounded, and for every casualty or injured person, there will be exponentially more who may seek evaluation. This requires the ED to establish treatment areas that may be outside of its regular departmental confines.13 An initial triage may be set up outside the unit to allow for proper sorting of patients and reduce overcrowding. Communication through an Emergency Operations Center reduces the amount of confusion possible when an incident involves multiple organizations. Information technology improves communication in a disaster, but in a catastrophic event, it cannot be relied upon. Faceto-face communication and two-way radios with section leaders reporting off at regular intervals offer a “lowtech” solution that is successful with very few setbacks. SPECIAL DISASTER SITUATIONS

Another type of disaster that could affect many communities is a chemical disaster. Examples could include an explosion at a chemical plant or the derailment of a train carrying a dangerous chemical. It is beyond the scope of this module to discuss the full response to a chemical disaster, but some key principles must be considered when encountering these situations. One thing that makes chemical disasters unique is that patients are likely to retain chemicals on their clothing and body that can go on to contaminate others. This would increase the scope of the disaster by affecting new patients, including healthcare workers. Isolating and decontaminating chemically contamWWW.ORTODAY.COM

SCI Diagram

Source: FEMA

inated patients minimize this risk. Once chemical involvement is suspected, all personnel should remain upwind from the scene and should not approach the area without appropriate protective equipment. If the patient arrives at the hospital with possible chemical contamination, the patient should not be brought into the department. This often violates the principals of “patient first” that most healthcare professionals adhere to in regular practice. Healthcare workers must put their own safety, as well as the safety of coworkers and other patients, first.12,14 A “hot zone” will be identified where chemically contaminated patients are isolated. The only personnel who should be present in this zone are those in appropriate personal protective gear. The main activity in the hot zone is the removal of clothing. As much as 80% to 90% of chemical contaminants may be removed with the clothing. The quicker the clothing is removed, the less the skin will be contaminated; therefore, removal of clothing

should not be delayed. Avoid lifting clothing over the head to prevent secondary contamination of the face. Consider, instead, cutting off clothing.15 Because of the risk to healthcare workers, the only medical care provided in the hot zone is lifesaving care, such as airway and breathing interventions.14 From the hot zone, patients are moved to the warm zone. This is the area where the patient will be cleansed with water. Cover all open wounds to prevent contaminating them further with running water. Be careful not to cause abrasions or other breaks in the skin during the decontamination process, which could increase contamination. The skin should be thoroughly washed using a low water pressure to prevent further skin damage. The patients should tilt their heads back, raise their arms, and spread their legs to ensure creases in the body are decontaminated, turning 90 degrees periodically to expose all areas of the body to the stream of water. Take precautions to prevent runoff from September 2017 | OR TODAY

IN THE OR CONTINUING EDUCATION CE681B the head from getting into the eyes, nose, or mouth.15 From the warm zone, decontaminated patients are moved to the “cold zone.” This is the only zone in which healthcare workers do not need to wear special protective equipment. However, workers should not move freely between the warm and cold zone, thus causing the cold zone to become contaminated. Because patients in the cold zone are decontaminated, they can safely be given full medical care beyond the life-saving care provided in the hot zone. Poison control should be consulted to determine the appropriate care for the specific chemical to which the patient was exposed. It is important to note that activation of hot, warm, and cold zones is generally restricted to situations in which there is potential contamination of chemicals or other substances (such as radiation). Although exposure to radiation is much less common than exposure to chemicals, it is no less dangerous to both the patients initially contaminated and healthcare workers who may respond. As in chemical incidents, healthcare workers involved in the care of patients with radiation exposure must remain upwind of the incident and keep the protection of themselves and others as a priority. This means setting up hot, warm, and cold zones in the same way as described with chemical incidents. Like chemical exposures, patients should be immediately undressed as that will remove as much as 90% of the radiation. Clothing should be removed carefully to prevent aerosolization of radiation particles, leading to secondary contamination in the surrounding area. A radiation-measuring device should be used to identify the degree of radiation on the patient before decontamination when available. The radiology department of the hospital will usually be a resource for this equipment and expertise.16 As with chemical exposures, patients 34

OR TODAY | September 2017

contaminated with radiation should be showered after their clothing is removed. Cold water may close the pores of the skin, reducing the effectiveness of decontamination, and hot water may increase the internal absorption of radiation. Therefore, tepid water should be used along with soap for decontamination. The patient should be decontaminated until the level of radiation on the skin is determined to be less than two times the background radiation. Additional focused decontamination of open wounds and body orifices may be required in the cold zone as these tend to have higher doses of radiation that may not be thoroughly decontaminated in a shower.16 Disasters involving biological agents require another set of considerations. When large numbers of patients are exposed to a biological or infectious agent, they are unlikely to be aware of the exposure until days after the event, when the symptoms of the illness begin to manifest. Therefore, decontamination would no longer be appropriate, because patients have likely changed their clothing and showered numerous times since exposure. Unique considerations when facing a biological event include the recognition and containment of the event. Unlike the unpleasant odors associated with chemicals or the grotesque burns associated with radiation, patients exposed to biological agents may appear to have communicable diseases that seem routine. It requires an astute healthcare worker to notice clusters of patients presenting with common complaints and then recognize a biological event.17 Suspicions of a biological disaster should be reported to the hospital infection control department, the state health department, and sometimes the Centers for Disease Control and Prevention. Once a biological disaster is identified, appropriate isolation precautions and patient isolation need to be under-

taken. This may involve creating unique treatment areas and equipment isolated from other patients to prevent further disease transmission. The success of the response to a disaster is multifold. It requires intensive planning by all parties involved, starting with government agencies and extending to every other entity that will be asked to respond, from prehospital agencies to every available healthcare provider. But despite all the planning, success will ultimately depend heavily on those at the frontline who will provide the actual care. Are you, as a healthcare provider, prepared to respond to a disaster? Have you involved yourself in disaster drills? If a shooter opens fire in your community, do you feel you could be an integral member in caring for an influx of multiple severely injured patients? Do you know your community’s and institution’s disaster plan and how you fit into that plan? Do you know what resources are available to help you in this situation? The time to find the answers to these questions is now, not during the disaster. Guy H. Haskell, PhD, JD, NREMT-P, has been involved in EMS as a provider, instructor, consultant, and writer for many years. He is executive director of Emergency Medical and Safety Services Consultants LLC in Bloomington, Ind., and a paramedic with Indianapolis Emergency Medical Services. Jeanne Seelye, MSN, RN, CEN, is the clinical educator for a 45-bed ED. She has 17 years’ experience as an emergency medical technician-intermediate in the volunteer fire service and coteaches for the paramedic program at the community college level. Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN, is the owner of Solheim Enterprises and an educational consultant who speaks internationally on motivational WWW.ORTODAY.COM

CONTINUING EDUCATION CE681B

and clinical topics. Solheim has also written and edited numerous books and journal articles and runs his own not-for-profit medical organization that sends medical teams into the developing world. References 1. Furin MA. Disaster planning. MedScape Web site. http://emedicine.medscape.com/article/765495-overview. Published April 28, 2014. Accessed May 18, 2016. 2. Noji EK, Crook JE. Natural disaster management. In: Auerbach PS, ed. Wilderness Medicine. 6th ed. Philadelphia, PA: Elsevier; 2012: 1723-1732. 3. Assid PA. Disaster management. In: Trauma Nursing Core Course. 7th ed. Des Plaines, IL: Emergency Nurses Association; 2014. 4. Romig L. The Jumpstart pediatric MCI triage tool. JumpStart Triage Web site. http://www.jumpstarttriage.com/Home_Page.php. Published 2011. Accessed May 18, 2016. 5. Navin M, Sacco W, McCord T. Does START triage work? The answer is clear! Ann Emerg Med. 2010;55(6):579-580. doi: 10.1016/j.annemergmed.2009.11.031. 6. Kirkwood S. NIMS and ICS: from compliance to competence. EMS World. 2008:1. http://www.emsworld.com/article/10321278/nims-and-ics-from-compliance-to-competence. Accessed May 18, 2016. 7. FEMA Incident Command System for Emergency Medical Services: Student Manual. Emmitsburg, MD: United States Fire Administration, National Fire Academy; 1999:1-7. 8. Incident command and responsibilities. FEMA Incident Command System for Emergency Medical Services: Student Manual. Emmitsburg, MD: United States Fire Administration, National Fire Academy; 1999:2-14. 9. FEMA Incident Command System for Emergency Medical Services: Student Manual. Emmitsburg, MD: United States Fire Administration, National Fire Academy; 1999:1-8. 10. FEMA Incident Command System for Emergency Medical Services: Student Manual. Emmitsburg, MD: United States Fire Administration, National Fire Academy; 1999:4. 11. Incident command responsibilities. FEMA Incident Command System for Emergency Medical Services: Student Manual. Emmitsburg, MD: United States Fire Administration, National Fire Academy; 1999:2-2/2-14. 12. Schultz CH, Koenig KL. Disaster preparedness. In: Marx JA, Hockberger RS, Walls RM, Rosen’s Emergency Medicine. Philadelphia: Elsevier. 2014:2457-2468. 13. Incident command responsibilities. FEMA Incident Command System for Emergency Medical Services: WWW.ORTODAY.COM

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

DEADLINE Courses must be completed by 6/30/2018 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 In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina 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

September 2017 | OR TODAY

IN THE OR CONTINUING EDUCATION CE681B Student Manual. Emmitsburg, MD: United States Fire Administration, National Fire Academy; 1999.7-1. 14. Janssen M, Lee J, Bharosa N, Cresswell A. Advances in multiagency disaster management: key elements in disaster research. Inf Syst Frontiers.

2010;12(1):1-7. http://link.springer.com/article/10.1007/s10796-009-9176-x#/page-1. Accessed May 18, 2016. 15. Jagminas L. CBRNE: chemical decontamination. MedScape Web site. http://emedicine.medscape.com/ article/831175-overview. Updated Au-

gust 26, 2015. Accessed May 18, 2016. 16. Decontamination procedures. Chemical Hazards Emergency Management Webs site site. http://chemm. nlm.nih.gov/decontamination.htm. Published November 2014. Accessed May 18, 2016.

CLINICAL VIGNETTE You are an EMT on the interstate returning to your station after transporting an asthma patient to the ED. In the median you see what appears to be a recreational vehicle on its side. The front has severe damage, and the roof is split open. There are at least 20 people in the median; some appear injured, and others appear to be trying to take care of them. You turn on your emergency lights, pull off onto the median and don your yellow American National Standards Institute vests. 1. WHAT SHOULD BE YOUR NEXT ACTION?

a. Exit the ambulance and do a scene size up b. Find the most seriously injured patient and begin treatment c. Grab your triage tags and begin to triage patients d. Contact dispatch, inform them of the general situation, and establish incident command

2. WHAT AGENCY SHOULD ESTABLISH INCIDENT COMMAND?

3. WHAT ZONES NEED TO BE ESTABLISHED FOR THIS SCENE?

a. Warm and cold b. Hot, warm, and cold c. None d. Warm only

4. YOU ARE OUT IN CHARGE OF THE TRANSPORT SECTOR. AMONG THE INJURED ARE THREE MEMBERS OF THE SAME FAMILY, ONE WITH MODERATE INJURIES, TWO WITH MINOR INJURIES. YOU SHOULD:

a. Send the moderately injured patient to a trauma center and the other two to the community ED b. Send each patient to a different ED to prevent overwhelming any one hospital c. Ask the patients where they want to go and send them to that facility d. Do your best to keep the family together

a. Local police b. EMS c. Fire d. State police

1. Correct Answer: D. Although you donâ&#x20AC;&#x2122;t yet have any details, it is obvious this is a mass casualty incident in that it will require more resources than you have on hand and multiagency cooperation. By establishing incident command, you create a framework for requesting and organizing those additional resources.

4. Correct Answer: D Unless there is a pressing need to not do so, keeping family members together will make postincident organization much easier than trying to reunite dispersed families. dangerous substances, it is not necessary to establish zones. 3. Correct Answer: C Since there is no indication of danger of fire, explosion, or OR TODAY | September 2017

2. Correct Answer: B The first unit on scene establishes command, regardless of agency. Once command is established, it can be transferred according to the type of incident and local procedures.

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CORPORATE PROFILE

CORPORATE PROFILE KEY SURGICAL

ey Surgical recently announced a merger with Interlock and Clinipak, two European market leaders that also focus on products for the OR and sterile processing/central service departments. The merger has created a global provider in sterile processing and OR supplies. The three companies, which will continue to operate under their existing names, have highly respected brands, and are regarded for their expertise, broad product offering and exceptional customer service.

“Our merger allows us to offer hospitals and surgical centers a much broader portfolio of products and supplies; supporting the dedication to patient safety both in the OR and in instrument reprocessing,” Key Surgical Marketing and Communications Manager Alana Suomela explained. OR Today magazine interviewed Suomela, Kasey Koenig (Regulatory), and Lindsay Brown (Clinical Education Manager) to find out more about Key Surgical and what customers can expect as the company provides solutions amid continued growth.

CAN YOU SHARE A LITTLE BIT ABOUT THE COMPANY’S HISTORY AND SUCCESS?

Suomela: Key Surgical was started by three women in 1988 who, having years of combined experience in the health care industry, saw a need for a one-source supplier of high-quality, 38

OR TODAY | September 2017

sterile, ready-to-use products in the operating room. Soon after, they saw the opportunity to expand the business to include products to clean, protect, and identify surgical instrumentation throughout the decontamination and reprocessing process. A one-stop shop paired with excellent, second-to-none customer service proved to be just what hospitals and surgery centers across the U.S. needed to maximize efficiencies in supply chain by ensuring surgical supply needs were met in a timely, costefficient manner. Key Surgical became the “one to beat” in the marketplace. In 2005, Key Surgical was acquired by Brian O’Connell and Scot Milchman who, like the women who started the company, were long-time friends and professional peers in the medical device industry. Brian and Scot grew the business of Key Surgical on the principals set by the founding women.

As the number and complexity of surgical procedures increased year over year the need for a wider variety of products to clean, identify, protect, store, and transport surgical instrumentation grew. The brand evolved to what it is today; a company that holds true to its roots in high-quality products and exceptional customer service. Their combined focus on growth and always doing the right thing for customers comes natural. One might even say that “the apple doesn’t fall far from the tree” as one of the founding women is Scot Milchman’s mother, Gail. Today, Key Surgical serves nearly 10,000 hospitals and surgical centers around the world. Key Surgical employs customer-facing teams such as customer service, sales, and marketing that are laser-focused on providing solutions to the operating room and the sterile processing/central service department. Combined with a robust operational infrastructure at the headquarters in Eden Prairie, Minnesota, are internal quality and regulatory, supply chain, finance, contracts, and clinical education departments. Key Surgical truly stands behind its mission statement: Grow by providing the quality products, value, and service that our customers want, when they want them. WWW.ORTODAY.COM

SPECIAL ADVERTISING SECTION

HAT ARE SOME ADW VANTAGES THAT YOUR COMPANY HAS OVER THE COMPETITION?

Suomela: Key Surgical’s focus on the customer experience gives us the incredible opportunity to remain the market leader for sterile processing and operating room supplies. During business hours, customers call Key Surgical and get a live person right away on the phone, not an automated machine. The customer service team is trained on product and process; their ability to shape the customer journey is something we value greatly at Key Surgical because we know our customers expect it and we know they deserve it. We talk about value and service but we truly live and breathe it through our ability to manufacture our own products which allows us to closely monitor the quality. We offer same-day shipping, allow customization of many of our products, have the widest range of sterile processing products on the market today, and provide valuable tools to the hardworking professionals in the industry by way of education. In the past year, Key Surgical has hired a clinical education manager and developed an education program for our customers. Certification in sterile processing requires a certain amount of continuing education credits (CEUs) each year to maintain WWW.ORTODAY.COM

the title and the CEUs designed by the clinical education manager are invaluable training material to anyone (certified or not). The CEUs have been presented in a number of ways; in person at educational conferences around the country and they are accessible our company website. The CEUs are both IAHCSMM and CBSPD certified.

LEASE SHARE SOME COMP PANY SUCCESS STORIES WITH OUR READERS – ONE TIME THAT YOU “SAVED THE DAY” FOR A CUSTOMER.

Brown: We are a resource and trusted partner for our customers and this is a valued benefit when hospitals undergo TJC or CMS inspections. Often times, our sales team members answer product-related or IFU questions that inspectors have once they are on-site. In one specific instance, an inspector was dissecting the policies and procedures in a Sterile Processing Department decontam area of a hospital. The week prior, the sales rep had completed a cleaning brush assessment and helped implement a manual cleaning policy for this hospital which included training of all staff members so that regardless of who was asked questions by an inspector everyone knew how to answer correctly. This led to an impressed inspector and an endlessly grateful customer.

WHAT ARE SOME CHALLENGES THE COMPANY HAS FACED?

Koenig: The medical device regulatory environment is constantly shifting. The pressures imposed on medical device manufactures to produce safer devices with more verification and validation steps that are cost effective is increasing. In this past year alone, the new quality management system standard ISO 13485:2016 was released, along with the Medical Device Single Audit Program (MDSAP), FDA Unique Device Identification (UDI) Compliance for Class II devices was required and, most recently, the MDR (European Medical Device Regulation) was published. The challenge lies in the logistics of updating your quality management system to meet regulatory requirements of multiple countries with different deadlines. Key Surgical has been able to overcome that challenge by implementing an early adoption approach to certain standards and regulations. For instance, Key Surgical began preparing for UDI in 2013 when the original drafts were published and we most recently received certification to ISO 13485:2016 (compliance isn’t mandatory until 2019). Staying on top of industry quality and regulatory requirements allows us to quickly adapt to the environment while producing safe and effective devices. September 2017 | OR TODAY

CORPORATE PROFILE

AN YOU EXPLAIN C YOUR COMPANY’S CORE COMPETENCIES?

Suomela: Key Surgical goes beyond just being a vendor. We focus on fostering collaborative relationships with customers to become a partner and we do this in a number of ways. One way is the development of in-person and online education/ training opportunities; ensuring that they are following standards and recommended practices with a focus on patient safety through effective decontamination and sterilization methods. Customers can earn CEUs from Key Surgical through our online program, during an in-service at their facility, and at regional and national conferences. Our customer service team is cross-trained on products and resources so that customers can quickly get any information they need in order to make a decision on a product, or access product information such as instructions for use (IFUs). In addition to having documentation such as IFUs easily accessible on our website, we work closely with oneSource Document Management Services, the world’s largest complete online database service of manufacturer’s IFUs, to also ensure that the documentation our customers seek is readily available and always up-to-date. Many of our customers access this global database on a daily basis for their various documentation needs. We are dedicated to being where our customers need us – whether that means with product solutions, IFUs or educational opportunities. Flexibility is key when it come to our customers’ needs – we offer customization of many of our products to fit the varying needs in SPD and the OR. We allow customers to purchase products from us without requiring minimum orders and we also offer bulk packaging for customers who wish to do so. We also partner with various group purchasing organizations (GPOs) to help customers meet their contract compliance needs. Key 40 OR TODAY | September 2017

Surgical also has a certified quality management system that allows us to stay committed to producing the highest quality products in the medical industry by meeting customer and regulatory requirements. Also, our QMS allows us to continually improve our products, processes and systems.

TELL US ABOUT THE COMPANY’S FACILITY?

Suomela: Key Surgical is located in Eden Prairie, a suburb of Minneapolis. Our headquarters is a 70,000 square foot office building, nestled in a beautiful, wooded area. Our facility also features an ISO Class 7 cleanroom, where select OR products are prepped for sterilization before sale.

WHAT SHOULD WE KNOW ABOUT YOUR EMPLOYEES?

Suomela: Part of our mission is to hire and retain good people who understand that nothing happens until a customer decides to do business with us. Everyone here understands the impact our products have on patient safety in terms of positive surgical outcomes and reducing patient risk. We require all of our sales team members to be

IAHCSMM vendor certified (CCSVP) and all new hires are crosstrained in various departments to gain a full understanding of how essential each department is to the overall success of Key Surgical. Each Key Surgical team member brings a wealth of knowledge and experience and their everyday contribution to our mission is “key” to how we operate and deliver on promises to our customers.

WHAT IS YOUR COMPANY’S MISSION STATEMENT?

Suomela: We believe that nothing happens until a customer decides to do business with us – meaning that every single Key Surgical employee is vital to the success of our company through their role in the customer experience. We do this by first hiring and retaining good people. Next, we focus on growth through providing the quality products, value, and service that our customers want, when they want them. Finally, we believe in giving back to our community in which we operate through volunteer and donation efforts. To find out more about Key Surgical, visit www.keysurgical.com. WWW.ORTODAY.COM

Emergency Preparedness BY DON SADLER

ometimes it can be easy to grow numb to the wave of disasters that seems to occur in our world on a regular basis. These include natural disasters like hurricanes, tornados and earthquakes as well as terrorist attacks, mass shootings and violent intruders. Communities depend on hospitals and ambulatory surgical centers (ASCs) to be prepared to provide emergency services in the aftermath of a disaster. So, these health care facilities can’t afford to be numb or complacent about disaster threats. A KEY ROLE According to Roslyne Schulman, the director of policy at the American Hospital Association (AHA), hospitals play a key role in the nation’s emergency preparedness and response as part of America’s health care infrastructure. “Hospitals are pivotal to disaster-response activities, whether they are rural or critical access hospitals or Level 1 trauma centers,” says Schulman. Schulman notes that emergency preparedness for health care facilities requires a significant investment in staff and resources.

Emergency Preparedness

advance with community safety and emergency networks, including area hospitals, ambulance services and the police and fire departments,” says Jan Davidson, MSN, RN, CNOR, CASC, the director of the Ambulatory Surgery Center Division of the Association of periOperative Registered Nurses (AORN). “When there is a large influx of patients, this network of providers needs real-time communications to ensure proper triage,” Davidson adds. F I N A L RU LE FRO M T H E C M S

Jan Davidson, MSN, RN, CNOR, CASC, The Director of the Ambulatory Surgery Center Division of (AORN).

“In times of disaster, communities look to hospitals not only to care for the ill and injured, but also to

To help health care facilities make emergency preparations for natural and manmade disasters, the Centers for Medicare & Medicaid Services (CMS) published a final rule last fall establishing new emergency preparedness requirements for hospitals and ASCs. In a Regulatory Advisory, the AHA stated that it believes the new requirements “reflect a common-

“ When there is a large influx of patients, this network of providers needs real-time communications to ensure proper triage.” – Jan Davidson provide food and shelter and help coordinate recovery,” she says. Preparedness isn’t a one-time investment, Schulman adds. Rather, it is a dynamic process that changes over time. “Hospitals and health systems need to learn from each emergency situation and incorporate new technology into their emergency readiness plans that gives them the ability to care for their communities when a disaster or terrorist attack occurs,” she says. “ASCs should prepare for an influx of patients by working in 44 OR TODAY | September 2017

sense approach to help hospitals protect patients and communities during disasters.” Along with creating a consistent set of emergency planning regulations across provider-types, “the CMS has provided flexibility in meeting the new standards,” stated the AHA in the Regulatory Advisory. The new emergency preparedness requirements will be implemented on November 15, 2017. They will require health care facilities to: • Conduct risk assessments using an all-hazards approach.

• Develop emergency preparedness plans, policies and procedures. • Create distinct communications plans. • Establish training and testing programs. The standards stipulate that health care facilities must conduct a thorough evaluation of their existing emergency preparedness programs to determine necessary changes and additions needed to comply with the final rule. Facilities also must review and update their emergency preparedness plans on an annual basis if they do not do so already. There are six key aspects of the final rule for health care facilities: 1. Generator location and testing – Generators must be located in accordance with National Fire Protection Association (NFPA) standards when a new structure is built or an existing structure is renovated. 2. Community involvement – Health care facilities are strongly encouraged to engage in community collaboration in their disaster planning efforts. 3. Integrated, system-wide planning – Integrated health systems have the option to maintain one coordinated emergency plan in cases where a single plan improves preparedness. 4. Development of a communications plan – Health care facilities must have a detailed communications plan that includes contact information for staff, physicians, other hospitals, entities providing services under arrangement, volunteers and relevant emergency preparedness officials. 5. D evelopment of policies and procedures for various provisions – Health care facilities must develop policies and procedures based on the risk assessment, emergency plan and communications plan. WWW.ORTODAY.COM

6. Testing of the emergency plan – Health care facilities must conduct two exercises annually to test the emergency plan, monitor and document these tests, analyze the results, and update the plan as needed. PA RT O F T H E EN V I R O N M E N T

Jeff Solheim, MSN, RN, CEN, TCRN, CFRN, FAEN, the president of Solheim Enterprises, has been involved in a number of health care facility disaster scenarios throughout his career. “As an emergency department nurse and emergency department director, disasters are part of our environment,” he says. Among the disaster scenarios Solheim has been involved in were several chemical incidents in which patients required decontamination and care, as well as a number of motor vehicle collisions in which large numbers of critically injured patients were transported simultaneously. “My main advice to every health care system out there is to pour adequate resources into the mitigation and preparation phases of disaster management,” he says. “A well- designed and well-rehearsed disaster plan equates to saved lives and reduced staff stress during a disaster.” Mitigation and preparation are the two main steps that should be taken before a disaster occurs, Solheim explains. “Mitigation requires performing a hazards vulnerability analysis, or an HVA,” he says. “Here, the staff will try to determine all potential man-made or natural disasters that could possibly affect the facility.” Once potential disasters are identified, the facility should develop steps to minimize their potential negative effects. “This includes devising an alternate communication plan in case landline phone lines, cell towers WWW.ORTODAY.COM

and other electronic forms of communication are impaired,” says Solheim. The preparation step recognizes the fact that, regardless of how thorough a facility’s HVA is, it could still be severely impacted by a disaster. “Preparation involves creating an incident command structure, drafting a formal disaster response plan, training all facility staff on the plan, and conducting drills to test the plan,” says Solheim. P R E PA R I N G FO R D I R EC T I M PA C T

In addition to preparing for a large influx of patients due to a disaster in the area, health care facilities also must make preparations in case they are directly impacted by a disaster themselves. “Emergency preparedness is a required exercise for accredited facilities of any kind,” says Davidson. “Conducting emergency management drills at least once per calendar quarter is mandatory.” “The first step in emergency preparedness is to determine if you can remain fully operational or if you’ll need to reduce services or transfer patients to another facility,” says Jonathan Flannery, the senior associate director of advocacy at the American Society for Healthcare Engineering (ASHE). “Health care facilities need to understand the memorandums of understanding (MOUs) that are in place with other facilities with regard to transferring patients,” adds Flannery. “Are these facilities across the street or hours away? You don’t want to be too dependent on a facility across the street because they could be affected by the disaster, too.”

Jeff Solheim, MSN, RN, CEN, TCRN, CFRN, FAEN, The President of Solheim Enterprises

Facilities also need to make plans for how to mange patients who are in surgery or pre-op at the time of the disaster, as well as how to reschedule surgeries. “Patient tracking and handling of patient records is critical here because you don’t want to lose track of a patient during a disaster,” says Flannery. A C T I V E EN G A G EM EN T I S C RU C I A L

Flannery believes it’s critical that the OR staff actively engage with the facility’s disaster and emergency planning. “Communication is especially critical,” he says. “Active surgical patients are among the most at-risk patients in the facility when a disaster occurs, so the OR department must be diligent in its disaster preparations.”

“ A well-designed and well-rehearsed disaster plan equates to saved lives and reduced staff stress during a disaster.”– Jeff Solheim September 2017 | OR TODAY

CLINICAL NURSE EDUCATOR

SPOTLIGHT ON

CHRISTINA BOBCO BY MATT SKOUFALOS

hristina Bobco is the kind of student who excelled in high school without blinking an eye and graduated without any clear vision for her future. So after high school, she spent some time at Gloucester County College figuring it out.

“My mom’s an X-ray tech, so I thought, ‘Ultrasound sounds cool,’” Bobco remembers. “Pharmacy sounded awesome, but I hated how stuffy the school was.” An anatomy teacher asked her, “What do you want to do?” and pushed Bobco towards nursing, so did her mother’s best friend, a nurse whom she’d always regarded as a mentor. Nursing “just seemed like something she did versus being her life,” Bobco said; it gave a model for how to refine her vocational focus, inspiring her to “be professional but light-spirited.” “You should work to live, not live to work,” Bobco said. “You have to have a balance.”

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That distinction in no way diminished the workload she faced even after winning a full scholarship to Drexel University in Philadelphia, Pennsylvania. The school is known for its immersive co-op experience, which places students in vocational roles throughout their courses of study. Bobco was in a nursing class of 15—the first that the university had enrolled in the program. Five years later, she was back on campus, delivering remarks to a graduating class of 120. Bobco completed two cooperative learning experiences with Lourdes Health System in the course of her studies, spending six

months apiece in PACU and critical care nursing environments. When she was ready to graduate, the institution took her on full-time, in part because of her additional vocational experience beyond the student clinical experience. Fresh out of college, Bobco began working bedside as a newly minted critical care nurse. Many of her patients were recovering from cardiac episodes, and she worked the night shift, learning by doing.

September 2017 | OR TODAY

SPOTLIGHT ON

CHRISTINA BOBCO

“They would throw me to the wolves,” Bobco said. “They would let me sink, and then come in at the last second and show me what to do. After my orientation, they were no longer precepting me, because I knew what I was supposed to do, but what was missing was the mentorship that would help me appreciate the finesse of the job.” Bobco welcomed all of it; fell in love with balloon pumps, swan ganz catheters, and learning how to titrate medications precisely. She also viewed critical care nursing as a critical springboard to anesthesia school, which was where she believed she’d find her ultimate career path. After racking up six figures’ worth of student loans, she was finally ready to take the national certification examination – right as she was finalizing her divorce. She never passed the test. School again had come easy to Bobco, but it had also become a refuge while the rest of her life grew too overwhelming to manage. When it was all done, she knew she could do the job, but couldn’t pass the test to earn her certification. It was a major personal setback, and yet failing was the very thing that again helped her find clarity around her career plans. It was also something she had to face publicly. “I had to face people that I was in school with,” Bobco said. “You pick it up, put your big-girl panties on. They don’t live your life. They’re not paying your bills. Things happen for reasons.” Bobco took up travel nursing, and eventually parlayed that experience into a local per-diem job. She remembers the challenges of the position falling far short of any of the stresses she’d encountered in critical care or in anesthesia school. And along the way, she met and married her second husband, with whom she has two young boys. Live to work, not work to live. “I got caught up in trying to make a decision,” Bobco said. “[Anesthesia nursing] is a nice paycheck, but that shouldn’t be the only reason why you go to work. Nursing fulfills your heart.

OR TODAY | September 2017

THE BOBCO FAMILY It fulfills your soul. When you don’t have that or lose that, you’re done.” Today, Bobco is no longer working at the bedside, but neither is she chasing continuing education credits with a paycheck in mind. Instead, she works as a clinical nurse educator at Lourdes Medical Center of Burlington County, New Jersey. It’s a lower-acuity setting than her critical-care positions with Lourdes – she’s at a community hospital, not a teaching hospital – but the benefits of her expertise and scholastic acumen are now turned towards helping to advance the careers of the nursing professionals around her. “My job is new hires, and I have to make sure they’re aligned with certain preceptors, making certain benchmarks,” Bobco said. “What I’m finding is that that lack of mentorship after the preceptor’s done, it’s missing, either because the person’s not selecting that mentor themselves or the system’s not set up to have that mentorship.” Instead, Bobco is helping her charges learn to reach out for what they need, the better to provide for

their own professional and emotional welfare, all while helping build a workplace more aligned with both. “A closed mouth doesn’t get fed,” she said. “If you don’t speak up, you’re not going to get the things that make you happy. So we’re talking in our department now to create this. I have a loyalty to the hospital, the mission they have and the community they serve. I don’t look at it as just a paycheck.” Today, Bobco said she feels like the nursing field is still sweeping her up in its wake. She doesn’t know what’s next for her because health care is deeply variable. But helping develop nursing-based care pathways is a career that has, at long last, come clearly into focus for her. “You can’t complain unless you attempt to fix it,” Bobco said. “You have to be the one motivated to make yourself happy – nobody else is! Always have a thirst to build upon your current knowledge. Things change everyday and you want to be that resource who can give up-to-date information.”

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OUT OF THE OR FITNESS

BY MARILYNN PRESTON

EACH MOMENT WE HAVE A CHOICE

THE ART OF DE-AGING

ow is the perfect time to practice de-aging, a wonderful thing I discovered years ago on this tiny island in Southeastern Greece where I’m grateful to live, work and overdo it on fresh feta several months a year. De-aging – a smart practice for all ages – is to personal well-being what snapping photos is to a great vacation. And it’s what I decided to focus on last week when at least 100 friends and guests gathered at a favorite beach cafe to celebrate a funny, savvy new book, just out, called “All is Well: The Art {and Science} of Personal Well Being.” OK, full disclosure, it’s my new book, based on my 40 years writing the healthy lifestyle column you’re reading now. “40 years on the fitness beat,” I like to say to reassure the wary, “and still eating fries.” Kaz Tanahashi – now in his 80s – is the inventor of de-aging, I explained to friends from 14 countries. Greeks, Swedes, French, British, Italians, Dutch, Austrians, Australians, a couple from Tonga – it turns out that an interest in personal well-being knows no boundaries. De-aging is boundless too, Kaz 50 OR TODAY | September 2017

would say if he were here instead of traveling the world – painting, teaching calligraphy, spreading Zen teachings on what it means to live a good life. In fact it’s Kaz’s gorgeous enso – a one-stroke brush painting – that’s on the cover of “All is Well.” I held up the book for everyone to see, a swoosh of red and gold, an imperfect circle in a single bold brush stroke. “The enso contains the perfect and imperfect,” I read Kaz’s quote from the opening pages. “That is why it’s always complete.” I looked up at the crowd and saw many people nodding. It could have been the “All is Well elixir” (a healthy blend of the island’s best prosecco and fresh beet juice) but no. The audience understood. None of us are perfect humans leading perfect lives. We screw up; we make mistakes; we start again; and as time goes on, we hope to make choices that lead to a balanced

and joyful life. That’s what de-aging is all about. “De-aging isn’t a product or a program,” I kept reading. “It’s a concept, a way of slowing down the aging process without resorting to desperate anti-aging measures involving pills, plastic surgery or fetal lamb cells.” “De-aging is more active,” I quoted Kaz. “Each moment we have a choice. The choice is between doing something that ages us, or de-ages us, something that makes us more vital or less vital, more healthy or less healthy.” “If I’m tired, I can choose to take a walk, or I can watch TV. I can choose to relax and meditate, or I can smoke. I can overwork, or I can rest. I can take a job that is more stressful or less stressful ... and in this way, we can shape our life. Are we aging or are we de-aging? It’s an active choice.” The Kaz quote ended, and I continued. “Fortunately for all of us you don’t have to be a Zen master to figure it out. Will you have a donut and diet cola for breakfast or yogurt and fresh fruit? Hold onto anger or let it go? Choose to drive or walk, or bike?” “You can’t really control overall aging,” Kaz teaches, “but by doing de-aging, moment by moment, we can slow it down.” WWW.ORTODAY.COM

FITNESS

Slowing down is what we’re all choosing to do when we spend time here. We swim in the sea, read books, take walks. We make time to meet old friends and make new ones. We eat and drink together and tell stories about our children, our cancers, our concerns about these scorching hot summer days. I’m preaching to the converted, I think to myself as I’m closing, but I’m not really preaching. I’m a journalist, reporting on what I’ve learned, what many already know. Before I thank everyone for coming, I ask: “If you were going to practice deaging, what would you do?” • “I’d daydream more,” someone shouted.

• “I’d dance more.” • “I’d spend more time with Sabena!” (a local goddess). Lots of laughter. • “I’d buy your book and read it!” Aah ... my own moment of de-aging. What’s yours? Marilynn Preston is the author of Energy Express, America’s longest-running healthy lifestyle column. Her new book “All Is Well: The Art {and Science} of Personal Well-Being” is available now on Amazon and elsewhere. Visit Creators Publishing at creators.com/books/ all-is-well to learn more. For more on personal well-being, visit www.MarilynnPreston.

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September 2017 | OR TODAY

OUT OF THE OR HEALTH

BY LEXI PETRONIS FITNESSMAGAZINE.COM

HEALTH-FOOD FIGHT THE HEALTHIEST BUYS AT THE GROCERY STORE

ou know what you should choose when the choice is between a burger and grilled fish, or salad versus french fries. But some nutritional choices are a little harder to make.

TURKEY BURGERS VS. VEGGIE BURGERS

The winner: Veggie burgers. When made with ground breast meat, turkey burgers can be a lean source of protein. The reality? Premade patties are usually a blend of white and dark meat, so they can have five times the fat and up to 20 times more cholesterol than meat-free versions. “Veggie burgers also have about 4 grams of fiber and half the calories – around 100,” says Lori Lieberman, R.D., a dietitian in South Weymouth, Mass. They can be high in sodium, however, so choose a brand with 300 milligrams or fewer. INSTANT OATMEAL VS. STEEL-CUT OATS

The winner: Steel-cut oats. While both types of oats are good sources of cholesterol-lowering soluble fiber, “the instant kind are rolled out and steamed before being packaged to make them cook faster,” says Julie Kaye, R.D., a dietitian in New York City. Steel-cut oats are less processed. That means they take more 52

OR TODAY | September 2017

time to digest, which means they keep your blood sugar steady and help you feel full for up to three hours – twice as long as instant oats do. BROWN RICE VS. QUINOA

The winner: Quinoa. All whole grains have fiber, but quinoa is also loaded with 8 grams of protein per cup, says Julie McGinnis, R.D., a dietitian in Boulder, Colo. What’s more, the protein is the complete kind – typically found in animal sources like meat and eggs – meaning that it contains all nine of the essential amino acids your body needs to repair cells and make new ones. And quinoa takes just 20 minutes to cook, compared with up to 50 for brown rice. POTATOES VS. SWEET POTATOES

The winner: Sweet potatoes. Sweet potatoes have about the same amount of fiber (4 grams) as potatoes but 60 less calories. Where they really shine is in the vitamin department: One sweet potato delivers 438 percent of your daily value of vitamin A, while

a single spud serves up none. And sweet potatoes also provide about a third more vitamin C per serving. FROZEN YOGURT VS. SOFT-SERVE ICE CREAM

The winner: Frozen yogurt. “Most frozen yogurt contains probiotics, the good-for-your-gut bacteria found in regular yogurt that help keep your digestive system in check,” Kaye says. (To be sure, look for the words “live and active cultures” on the package, menu or website.) Surprisingly, both desserts have around 18 grams of sugar, but soft-serve has about 11 grams of fat and nearly 200 calories per half cup, whereas frozen yogurt packs about 115 calories and is often fat-free. To keep yourself from going overboard at self-serve fro-yo chains, hold the dispenser handle down for no more than five seconds. HUMMUS VS. GUACAMOLE

The winner: Guacamole. The main ingredients in these dips – chickpeas and avocado – both contain fiber, but avocados are also a good source of heart-healthy monounsaturated fats and potassium. Just stick to a 2-tablespoon serving of guac and pair it with baby carrots or bell pepper strips instead of chips to keep the calorie count in check. WWW.ORTODAY.COM

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September 2017 | OR TODAY

OUT OF THE OR NUTRITION

BY CARRIE DENNETT, M.P.H., R.D.N. ENVIRONMENTAL NUTRITION ENTREE

WHOLE GRAINS ARE PACKED WITH FLAVOR, TEXTURE

ne of the first things that comes to mind when you think about whole grains is how healthy they are. But even when nutrition and health are priorities, we eat with our eyes and eat to satisfy our taste buds. Yes, they are nutritious, but whole grains are also beautiful to behold and packed with flavor and texture.

HEALTH BENEFITS IN THE KERNEL

In their whole form, grains still have their bran and germ, making them rich in fiber, antioxidants and B vitamins. They also have some healthy fats. Refined grains are missing the bran, germ or both, leaving mostly starch. A study published last June in the journal Circulation found that people who ate the most whole grains (about 4 servings per day), compared with those who ate little or no whole grains, had a lower risk 54

OR TODAY | September 2017

of dying. The researchers reported that not only are whole grains fiber-rich, which helps lower cholesterol and stabilize blood sugar, but they have multiple bioactive compounds that could contribute to their health benefits. This study is just the latest to demonstrate the healthfulness of whole grains. It’s also consistent with research supporting the health benefits of plant-based diets – including the traditional Mediter-

ranean diet, in which whole grains play a significant role. But focusing on the health benefits may get in the way of fully appreciating the appeal of whole grains. SAVOR THE FLAVOR

To Maria Speck, author of “Ancient Grains for Modern Meals” and “Simply Ancient Grains,” the real motivation for using whole grains is flavor, with nutrition just a lucky side bonus. Growing up with German and Greek heritage, she says, “No one ever said, ‘You better eat your healthy whole grains.’ Instead, they were just part of our everyday meals.” TIPS FOR MAKING WHOLE GRAINS ABSOLUTELY DELICIOUS

Whole grains have fuller, more nuanced flavor, which can seem unfamiliar at first. Once your palate adjusts, your taste buds will have a new world to explore. WWW.ORTODAY.COM

NUTRITION

No More

Wheel obstructions

Plan ahead: Some of the most flavorful grains, like rye berries and wild rice have longer cooking times. Speck suggests cooking batches to refrigerate or freeze for later. Enjoy texture too: Speck says that whole grains have a spectrum of textures. â&#x20AC;&#x153;Oatmeal, polenta and millet can all be made into supremely comforting dishes.â&#x20AC;? Wheat berries, spelt berries and rye berries are chewy. Quinoa and brown rice are somewhere in the middle. Adjust accordingly: Whole grains and whole grain pasta often pair best with more assertively flavored sauces and ingredients that can match them, like those from the Mediterranean. Find great resources: Whole grains are everywhere, from magazines to cookbooks to the Internet. One online resource is the Whole Grains Council (wholegrains council.org).

Environmental Nutrition is the awardwinning independent newsletter written by nutrition experts dedicated to providing readers up-to-date, accurate information about health and nutrition in clear, concise English. For more information, visit www.environmental nutrition.com. WWW.ORTODAY.COM

September 2017 | OR TODAY

OUT OF THE OR RECIPE

BY DIANE ROSSEN WORTHINGTON ENTRÉE

HERE ARE A FEW IDEAS TO PERSONALIZE YOUR PASTA SALAD: • Cooked chicken or shrimp • Pitted olives or toasted pine nuts • Chopped grilled vegetables • Chopped prosciutto or salami • Sun-dried tomatoes packed in oil

OR TODAY | September 2017

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RECIPE

CAPRESE PASTA SALAD FOR EASY SUMMER DINING

merica’s fascination with pasta salads has taken us a long way from the original macaroni salad. In the last few decades’ pasta salads have become colorful and fresh, relying on vinaigrettes and an array of seasonal vegetables, cheeses, meats, poultry and seafood to help them sparkle.

INGREDIENTS Caprese Pasta Salad Serves 4 to 6

FOR THE PASTA:

You’ll find varieties now include whole wheat, egg, cellophane, soba, quinoa and the standard semolina noodle. I like to use Italian style penne or fusil because it is so easy to eat with a fork. This vegetarian pasta salad combines the flavors of Caprese (tomato, mozzarella and basil) into a colorful salad. This is a welcome treat. The key is to find ripe tomatoes; multi-colored cherry tomatoes work well too. An added bonus

is that this recipe includes a no-cook sauce. Fresh mozzarella (I prefer the little fresh mozzarella balls called ciliegine) adds a creamy element to the salad. This is a basic recipe; feel free to add or subtract ingredients to make it into your own signature salad. Cooking pasta for a chilled salad requires a few tricks to ensure that the pasta doesn’t stick together. Cook the pasta in boiling water and separate the noodles while cook-

ing, using tongs or chopsticks. Check the pasta often and pull it out of the water while still slightly al dente since it will continue to cook. Drain the pasta and mix with the dressing or coat with oil to keep the noodles from sticking. You can make this up to one day ahead, cover and refrigerate. Perfect for a picnic, lunch on a boat, or as a star dish on a buffet, this pasta salad will be your backup for easy summer eating.

1 tablespoon salt 1 pound dried fusilli or penne FOR THE SAUCE: 1 1/2 pounds ripe tomatoes, coarsely chopped or cherry tomatoes, halved 1/2 cup coarsely chopped basil 1/4 cup finely chopped Italian parsley 3 medium garlic cloves, minced 1 pound fresh Mozzarella cheese, diced into 1-inch pieces 3 tablespoons red wine vinegar 1/3 cup extra virgin olive oil 1/2 cup freshly grated Parme-

DIRECTIONS

san cheese Salt and freshly ground black pepper to taste

1. Add salt to a large pot of boiling water. Add pasta and cook over high heat until al dente, about 7 to 10 minutes. Drain well. Place in a large serving bowl, mix the tablespoon of oil into the pasta to keep it from sticking and cool. Reserve. 2. In medium bowl combine all the sauce ingredients and mix to combine. Season to taste. Add any optional ingredients. 3. When the pasta is cooled, combine the sauce with the pasta, and mix well, Season to taste, cover and refrigerate until chilled, about an hour or until serving. WWW.ORTODAY.COM

Diane Rossen Worthington is an authority on new American cooking. She is the author of 18 cookbooks, including “Seriously Simple Parties,” and a James Beard Award-winning radio show host. You can contact her at www.seriouslysimple.com. September 2017 | OR TODAY

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OUT OF THE OR PINBOARD

PINBOARD

The News and Photos That Caught Our Eye This Month

OR TODAY

CONTESTS • SEPTEMBER • ARE YOU IN THE KNOW? Have you attended an OR Today webinar? Email a photo of yourself with a workbook from any OR Today webinar to Editor@MDPublishing.com to be entered to win lunch for your department. One lucky person will win a $50 gift card to Subway! Find out more about the OR Today webinar series, including workbooks and a calendar of upcoming webinars, at www.ORToday.com/Webinars.

PARENTING TIPS Parenting can be incredibly daunting for anybody, even more so if the child has behavioral, social or learning difficulties. Did you know that often, in these cases, the child may have left- or right-brain weakness – leading to outbursts, tantrums or full on melt-downs? But according to the education advocates at Brain Balance Achievement Centers (www. brainbalancecenters.com) there are 5 simple things parents can do to help with left- or right-brain weakness. TIP 1: GET YOUR CHILD MOVING Activities that involve active physical motion help children to read with greater comprehension and retain more information. Enjoy taking your child on an outdoor gallery walk, or take the fun indoors to an exploration-style, hands-on museum.

60 OR TODAY | September 2017

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TIP 2: COME UP WITH A DAILY SCHEDULE WITH YOUR CHILD Routines keep children grounded – and they are especially necessary during breaks, when the regular school schedule goes out the window. Let your child have input into their schedule – it will give them agency and make them feel empowered. TIP 3: SPEND TIME IN THE KITCHEN TOGETHER Let your child do simple activities like measuring ingredients, dividing up portions, and reading recipes. This reinforces their reading and math skills without making them feel intimidated. Plus, it helps you with dinner! TIP 4: HAVE YOUR CHILD START JOURNALING Have your child write about their feelings or thoughts. This is a fun way to boost their writing skills and show

{

Journaling prov healthy outlet ides a for a child. them that writing can be a meaningful outlet. And, of course, it will show in their assignments at school. TIP 5: LET YOUR CHILD GET HIS/ HER HANDS DIRTY Stimulate your child’s tactile and visual senses by letting them play with toys like sidewalk chalk and finger paints. These activities are sensory and help your child develop fine motor skills. They’re also plain old fun.

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PINBOARD

HOW TO OUTSMART STRESS If you’re all-too-familiar with the physical sensation of being stressed, it may be time to make some changes. “When you’re frantic, your muscles tighten and your heart speeds up,” says Fred Luskin, Ph.D., author of “Stress Free for Good.” Over time, this can take a toll on your body, leading to ailments such as stress-induced fatigue and

kinesiology at Point Loma Nazarene University in San Diego, Calif.

headaches. Here are a few ways that research suggests can help you keep calm and carry on.

turns out, being good at making decisions may be good for our health. Research shows that decisive people may have lower levels of the stress hormone cortisol than poor decision-makers. Want to be more resolute? Simplify your decisions by focusing on facts, so you understand what’s really at stake.

WORK UP A SWEAT When we’re stressed, the part of our brain that registers fear – the amygdala – lights up like a fireworks display. In response, our fight-or-flight response is triggered. That reaction serves us well when we need a shot of adrenaline to get us to safety, but it’s less helpful when we’re stressed about being stuck in traffic. One solution? Stick to your sweat sessions. Regular exercise can provide a satisfying release for frustration and other negative feelings. It may put a damper on stress hormones such as cortisol and adrenaline. And it can trigger your body to release endorphins, which are feel-good chemicals that can help boost your mood. The mood-boosting benefits aren’t limited to running. “Research shows that any form of physical activity will do the trick,” says Jessica Matthews, M.S., adjunct professor of

BE DECISIVE Yoga or spinning? Sandwich or salad? Break up or stay together? We face dozens of choices every day – some big, some small – and each of them taps into our mental capacity and requires us to make a decision. And, it

REFRAME PROBLEMS AS OPPORTUNITIES Your BFF cancels dinner at the last minute – again – and you assure her it’s OK, while fuming inside. After all, why risk ruining your friendship with an uncomfortable confrontation? Here’s why: Bottling up your feelings breeds anxiety. Instead, use a strategy called “reappraisal” to reframe upsetting situations. The next time you’re sweating something, pause and ask yourself: What are the positives? How can I look at this as a stimulating challenge rather than a problem? Maybe calling out your friend for being flaky will allow you to clear the air, prompt her to be more considerate and ultimately

Exercise releas es frustration. bring the two of you closer. Maybe a tough work assignment will help you learn and add to your resume. Changing the way you look at a situation can help you respond in a less stressful way. SEE EVERY GLASS AS AT LEAST HALF FULL Are you a pessimist? You may have a genetic predisposition to a negative outlook, but chances are you can change your outlook through your experiences. The best strategy is to deliberately avoid other pessimists and surround yourself with optimists whose positive vibes are infectious. It’s also important to feel as if you have a purpose every day – whether that comes from your work, family and friends or an activity like running races to raise money for charity. Having something that you’re passionate about, and achieving goals related to it, can help many people have a more optimistic outlook. - Kimberly Goad FitnessMagazine.com

“GIVE A MAN A FISH AND YOU FEED HIM FOR A DAY; TEACH A MAN TO FISH AND YOU FEED HIM FOR A LIFETIME.” -MAIMONIDES

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September 2017 | OR TODAY

INDEX ALPHABETICAL

AAAHC…………………………………………………………… 4

Flagship Surgical, LLC……………………………… 27

Pacific Medical……………………………………………… 6

AIV Inc.……………………………………………………………21

Healthmark Industries Company, Inc.…… 58

Palmero Health Care………………………………… 51

ASCA…………………………………………………………… 53

Innovative Medical Products…………… 22, BC

Paragon Services………………………………………… 37

Belimed………………………………………………………… 51

Innovative Research Labs………………………… 55

Pure Processing……………………………………………… 5

C Change Surgical………………………………………… 9

Jet Medical Electronics Inc……………………… 53

Ruhof Corporation……………………………………… 2,3

CSZ Medical………………………………………………… 49

Key Surgical…………………………………… 38-41, IBC

TBJ Incorporated………………………………………… 10

Cygnus Medical…………………………………………… 15

MD Technologies Inc.………………………………… 27

INDEX CATEGORICAL

ANESTHESIA Innovative Research Labs………………………… 55 Paragon Services………………………………………… 37 ASSOCIATION AAAHC…………………………………………………………… 4 ASCA…………………………………………………………… 53 CARDIAC PRODUCTS C Change Surgical………………………………………… 9 Jet Medical Electronics Inc……………………… 53 CARTS/CABINETS CSZ Medical………………………………………………… Cygnus Medical…………………………………………… Flagship Surgical, LLC……………………………… Healthmark Industries Company, Inc.…… Innovative Research Labs………………………… TBJ Incorporated…………………………………………

49 15 27 58 55 10

CRITICAL CARE Innovative Research Labs………………………… 55 DISINFECTANTS Cygnus Medical…………………………………………… 15 Palmero Health Care………………………………… 51 Ruhof Corporation……………………………………… 2,3 ENDOSCOPY Cygnus Medical…………………………………………… 15 Healthmark Industries Company, Inc.…… 58 Ruhof Corporation……………………………………… 2,3 ERGONOMIC SOLUTIONS Pure Processing……………………………………………… 5 FLUID MANAGEMENT SOLUTION Flagship Surgical, LLC……………………………… 27 MD Technologies Inc.………………………………… 27 GENERAL AIV Inc.……………………………………………………………21

OR TODAY | September 2017

INFECTION CONTROL Belimed………………………………………………………… 51 Cygnus Medical…………………………………………… 15 Healthmark Industries Company, Inc.…… 58 Palmero Health Care………………………………… 51 Pure Processing……………………………………………… 5 TBJ Incorporated………………………………………… 10

RESPIRATORY Innovative Research Labs………………………… 55

INSTRUMENT STORAGE/TRANSPORT Belimed………………………………………………………… 51 Cygnus Medical…………………………………………… 15 Key Surgical…………………………………… 38-41, IBC

SINKS Pure Processing……………………………………………… 5 TBJ Incorporated………………………………………… 10

INVENTORY CONTROL Key Surgical…………………………………… 38-41, IBC

51 15 58 10

MONITORS Pacific Medical……………………………………………… 6 OR TABLES/BOOMS/ACCESSORIES Innovative Medical Products…………… 22, BC OTHER AIV Inc.……………………………………………………………21 PATIENT MONITORING AIV Inc.……………………………………………………………21 Jet Medical Electronics Inc……………………… 53 Pacific Medical……………………………………………… 6 POSITIONING PRODUCTS Cygnus Medical…………………………………………… 15 Innovative Medical Products…………… 22, BC REPAIR SERVICES Cygnus Medical…………………………………………… 15 Jet Medical Electronics Inc……………………… 53 Pacific Medical……………………………………………… 6 REPROCESSING STATIONS Pure Processing……………………………………………… 5 TBJ Incorporated………………………………………… 10

SAFETY Flagship Surgical, LLC……………………………… 27 Healthmark Industries Company, Inc.…… 58 Key Surgical…………………………………… 38-41, IBC

STERILIZATION Belimed………………………………………………………… Cygnus Medical…………………………………………… Healthmark Industries Company, Inc.…… TBJ Incorporated…………………………………………

SURGICAL INSTRUMENT/ACCESSORIES C Change Surgical………………………………………… 9 Cygnus Medical…………………………………………… 15 Healthmark Industries Company, Inc.…… 58 Key Surgical…………………………………… 38-41, IBC SURGICAL MAT SOLUTIONS Flagship Surgical, LLC……………………………… 27 TELEMETRY AIV Inc.……………………………………………………………21 Pacific Medical……………………………………………… 6 TEMPERATURE MANAGEMENT C Change Surgical………………………………………… 9 CSZ Medical………………………………………………… 49 Warmers Belimed………………………………………………………… 51 CSZ Medical………………………………………………… 49 Waste Management Flagship Surgical, LLC……………………………… 27 MD Technologies Inc.………………………………… 27 TBJ Incorporated………………………………………… 10

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