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CONTENTS
features
OR TODAY | November 2017
STOP BULLYING
46
Advancing beyond cloth bundling, Innovative Medical Products created the Universal SteriBump®, and asks OR TODAY readers, "Why bundle, when you can bump?" Learn about this innovative company and how they're combating healthcare associated infections.
AND PROMOTE UNITY
50
STOP BULLYING AND PROMOTE UNITY Bullying has long been a problem in the OR that is too often swept under the rug. Writer, Don Sadler encourages readers to identify and eliminate bullying in their healthcare organization to avoid potentially disastrous consequences.
CORPORATE PROFILE: INNOVATIVE MEDICAL PRODUCTS
54
SPOTLIGHT ON: ELIZABETH SPARACO Meet our nurse spotlight, Elizabeth Sparaco whose dedication to nursing and education make her an inspirational mentor and example of what success in the field looks like. Discover how she empowers other nurses to be more autonomous.
OR Today (Vol. 17, Issue #9) November 2017 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 30269-1530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530. For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. © 2017
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November 2017 | OR TODAY
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CONTENTS
departments
PUBLISHER
John M. Krieg | john@mdpublishing.com
VICE PRESIDENT
Kristin Leavoy | kristin@mdpublishing.com
13
20
EDITOR
John Wallace | jwallace@mdpublishing.com
ART DEPARTMENT Jonathan Riley Sarah Sutherland Karlee Gower
ACCOUNT EXECUTIVES
Lisa Gosser | lgosser@mdpublishing.com Jayme McKelvey | jayme@mdpublishing.com
ACCOUNTING
30 INDUSTRY INSIGHTS 11 18 20 22
News & Notes AAAHC Update OR Today Live Recap ASCA Update
36
Kim Callahan
DIGITAL SERVICES Travis Saylor Cindy Galindo Jena Mattison Kathryn Keur
CIRCULATION Lisa Cover Melissa Brand
IN THE OR 24 27 28 36
Suite Talk Market Analysis Product Focus CE Article
OUT OF THE OR 56 Fitness 58 Health 60 Nutrition 62 Recipe 64 Pinboard
MD PUBLISHING | OR TODAY MAGAZINE 18 Eastbrook Bend, Peachtree City, GA 30269 800.906.3373 | Fax: 770.632.9090 Email: info@mdpublishing.com www.mdpublishing.com
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5 NURSES 5 NIGHTS IN NEW ORLEANS We’re giving away five sets of 5-night hotel stays in New Orleans to celebrate the grand opening of Global Surgical Conference & Expo Never before has AORN offered such a dynamic range of speakers, topics, activities, and innovations. Stay in style in a city known for its unique culture, cuisine, and festivities.
Register in October for Chance to Win More Info & Register www.aorn.org/surgicalexpo
INDUSTRY INSIGHTS NEWS & NOTES
STAFF REPORT
3M Helps Streamline Sterilization Workflow for V-PRO users Health care facilities now have access to a more comprehensive solution for vaporized hydrogen peroxide (VH2O2) sterilization processes with the U.S. Food & Drug Administration’s 510(k) clearance of 3M Comply Hydrogen Peroxide Indicator Tape 1228 and 3M Comply Hydrogen Peroxide Chemical Indicator 1248 for use in AMSCO V-PRO 1, AMSCO V-PRO 1 Plus and AMSCO V-PRO maX Low Temperature Sterilization Systems. This announcement, in conjunction with the recent FDA 510(k) clearance for a 24-minute 3M Attest Rapid Readout Biological Indicator System, means that the 3M VH2O2 sterilization process monitoring package is complete, further helping to streamline workflows and increase ease of use.
“With this announcement, sterilization professionals using VPRO sterilizer systems can now receive the workflow benefits of using the fastest BI readout currently on the market – along with a chemical indicator and indicator tape that utilize the same 3M indicator color change system, from blue to pink,” said Srini Raman, 3M business director of device reprocessing. “This comprehensive package can streamline the VH2O2 sterilization process, which makes it easier for sterilization professionals to consistently monitor every load.” The Comply Indicator Tape 1228 consists of non-cellulose material with pressure-sensitive adhesive on one side and blue indicator stripes on the other side.
The Comply Chemical Indicator 1248 also has blue indicator stripes. As with the exposure indicator on top of the 1295 Attest Biological Indicator, the indicator stripes turn from blue to pink after exposure to VH2O2. The Comply Hydrogen Peroxide Indicator Tape 1228 and Comply Hydrogen Peroxide Chemical Indicator 1248 are already cleared for use in STERRAD 100 System, STERRAD 100S System, STERRAD NX System (standard and advanced cycles), and STERRAD 100NX System (standard, flex, express and duo cycles) vaporized hydrogen peroxide sterilizers. • For more information, visit go.3M. com/VH202.
ChartWise Medical Systems Growth Continues ChartWise Medical Systems, Inc. has once again been recognized on the Inc. 5000 list. This year, ChartWise ranks 797th, placing the CACDI software pioneer in the top 16 percent of America’s top 5,000 fastest-growing privately owned companies. ChartWise’s three-year growth rate of 565 percent prompted the company’s inclusion in this year’s Inc. 5000. ChartWise also ranks first on Inc.’s list of the fastestgrowing privately owned businesses in Rhode Island for the second year in a row. “ChartWise and the ChartWise 2.0 CACDI software solu-
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tion have benefited greatly from a team of talented individuals rowing in the same direction for a single purpose – to provide the best documentation improvement tools and support in the health care industry,” said Dr. Jon Elion, founder and CEO of ChartWise. “Additionally, our amazing partners and customers at hospitals and medical centers across the country have supported us and served as such vocal advocates for our technology that our business continues to grow and thrive year after year. We’re competitive at ChartWise, so we’re already looking at new
ways to innovate and separate ourselves from the rest of the industry as we head toward next year’s Inc. 5000.” Companies eligible for the 2017 Inc. 5000 list must have generated at least $100,000 in revenue in 2013 and $2 million in 2016. These organizations must also be privately held, for profit, based in the U.S., and independently owned. • For more information, a full list of Inc. 5000 honorees can be found at http://www.inc.com/inc5000.
November 2017 | OR TODAY
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INDUSTRY INSIGHTS NEWS & NOTES
Belimed Launches New Multi-Enzyme Detergent Belimed Inc. has expanded its portfolio of multi-enzyme detergents with the addition of the new Belimed Protect Concentrate PLUS. This multi-enzyme detergent was designed and developed by Belimed to optimize the cleaning outcomes delivered by Belimed’s high performance washer/disinfectors. “Adding the Concentrate PLUS to our cleaning solutions portfolio provides an additional choice for customers to improve CSSD efficiency and lower operational costs” said Susan Harley, Belimed director of consumables business. Concentrate PLUS reduces dosing levels, which will minimize staff time on non-value added activities like product changeovers and inventory management. In addition, it
provides a lower risk of staff injury related to better ergonomics associated with smaller size containers. Efficiency results from less detergent and fewer product changeovers while processing the same number of loads in the washer/disinfector. Variability in water quality sometimes creates challenges like scaling, increased dosing levels and diminished cleaning performance for CSSDs. The Concentrate PLUS formulation performs consistently at all water hardness levels, minimizing concerns related to water quality. The Concentrate PLUS formulation, contains the same three enzymes (subtilisin-free protease, lipase and amylase) found in the Belimed Protect portfolio. “Our formulation is focused on
patient and staff safety, due to better cleaning efficiency and the elimination of substances such as subtilisin enzymes, fragrances and dyes where they are not needed,” Harley said. •
DePuy Synthes, JointPoint Inc. Join Forces DePuy Synthes has announced an exclusive U.S. agreement with JointPoint Inc. to co-market its proprietary software platform to provide an easy-to-use, surgeonfriendly navigation system that can help deliver improvements in surgical outcomes. JointPoint’s software provides non-invasive computer navigation, pre-surgical digital templating, case planning, and feedback while performing total hip replacement surgeries. JointPoint easily integrates with the anterior approach. Adding the JointPoint software to a surgeon’s protocol may help reduce leg length discrepancy and complications related to inaccurate cup placement and final implant
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OR TODAY | November 2017
selection – two of the most important considerations in hip replacement surgery – by providing pre-surgical digital templating and real-time, datadriven surgical decision making in the operating room. “We are thrilled to partner with JointPoint to help provide more predictive outcomes for surgeons and their patients,” said Aaron Villaruz, DePuy Synthes Joint Reconstruction. “By providing access to important information at key stages of the hip replacement process, together we can help surgeons streamline cases and allow for pre-surgical goals to be achieved more consistently.” One of the important features
of the JointPoint software is OneTrial, which can predict optimal implant combinations based on pre-surgical goals using just two images during surgery. Unique to DePuy Synthes implants is the ability of OneTrial to also provide precise recommendations on implant size and position to enable more confident adjustments and reduce OR time and fluoroscopy by eliminating re-trialing. Additionally, the JointPoint software helps streamline communications through a JointPoint calendar, case sharing, and case planning/collaboration. DePuy Synthes will begin comarketing the JointPoint software in the second half of 2017. •
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NEWS & NOTES
Humbles LapWrap Positioning Pad Provides More Security The Humbles LapWrap Positioning Pad, from Innovative Medical Products, secures patients’ arms by their sides during surgery. The LapWrap helps prevent shoulder injuries by not allowing a patient’s arm to fall from the side of the operating table. It also protects neurological structures by preventing hyperextension of the elbow. The easy-to-use, soft-foam pad not only positions patients’ arms but also allows access for IV tubes and leads for anesthesia. Providing more security for the patient and more versatility for the surgical team with its hook and loop material, the LapWrap is designed to meet AORN recommendations in “Recommended practices for positioning the patient in the perioperative practice setting” to prevent tissue injury and ischemia often caused by tucking patients’ arms at their sides. As one surgeon, who successfully tried the LapWrap pad, remarked, “It used to be a hassle tucking arms and this product makes it simple with its soft foam padding protecting the patient. I’ve asked to have it used in all my [surgical] cases.” The Humbles LapWrap is laminated on both sides with loop material and has additional hook fasteners on the center cut-out strap providing more options for securing the patient. This allows the positioner’s latex-free foam straps, for example, to be placed between the operating table and
the side rail, wrapped around the side rail and then back onto themselves for extra security. This addition helps to secure the patient directly to the OR table. The IMP positioning pad also comes with optional extension fasteners giving the surgical team more flexibility in securing patients during bariatric procedures The LapWrap is manufactured for single use and is universally sized to accommodate any patient. In addition, the innovative device protects the neurological structures of the elbow and acts as a warming blanket for the patient. Used with hook and loop fasteners, the LapWrap is simply configured for quick, easy securing of a patient’s arms and can be trimmed with scissors for better viewing of wire leads, tubing or connections. •
Nihon Kohden Launches Global Education and Training Platform Nihon Kohden has announced the launch of Nihon Kohden University, a global education and training platform designed to help health care professionals build and sustain technology expertise, optimize clinical practice and ultimately ensure quality patient care. Built to meet the unique needs of time-constrained health care practitioners and provider organizations, Nihon Kohden University offers anytime, anywhere access to: • A range of accredited instructor-led and virtual clinical courses. • Product-specific courses in patient monitoring and neurology, with sophisticated online simulations for navigating equipment prior to implementation. • Immersive training modalities specifically designed for adult learners, including virtual reality apps simulating everyday clinical practice. WWW.ORTODAY.COM
• A comprehensive, on-demand library of printable literature, including clinical resource guides, clinical references, self-study packets and more and • An array of offline, onsite training courses and consulting services that can be customized for each organization. Select Nihon Kohden University training courses are powered by HealthStream, giving users access to an array of advanced reporting features. Combined with Nihon Kohden University’s ease of use, the complete offering delivers training with significant cost and time savings for provider organizations. • For more information or to sign up for Nihon Kohden University, visit nkuniversity.org.
November 2017 | OR TODAY
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INDUSTRY INSIGHTS NEWS & NOTES
NuVasive Inc. Expands Headquarters NuVasive Inc. has announced the expansion of its global headquarters, including the creation of an innovation center of excellence where surgeons from around the world will be educated and trained on the latest NuVasive spine technology and procedures designed to drive clinical predictability and improve patients’ lives. NuVasive, founded in 1997 as a local San Diego medical technology startup, pioneered minimally invasive, lateral spine surgery and earned its reputation as one of the most innovative spine companies in the industry. Today, the Company ranks third in the global spine market and anticipates surpassing the $1 billion revenue mark at the end of this year. As the company continues to grow at an accelerated rate, it plans to renovate and further build out its world headquarters starting in January 2018. The company’s growth is reflected in several areas, including training more than 500 surgeons annually on its products and procedures at its San Diego campus, a commitment to increasing its R&D spend as a percent of revenue from 5 to 7 percent over the next several years, and creating jobs, locally and globally. NuVasive’s San Diego campus, located at 7475 Lusk Boulevard in Sorrento Valley, will increase by more than 100,000 square feet,
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OR TODAY | November 2017
bringing the total space to approximately 250,000 square feet. Expansion plans include renovating the current two buildings on campus and adding a third building. The newly renovated campus will include an innovation center of excellence, showcasing the company’s stateof-the-art product and procedural offerings and highlighting its world-renowned surgeon education. Additional features of the campus include: • an expanded surgeon education lab for onsite surgeon training and education • a prototype design facility with 3D printing capabilities • state-of-the art biomedical testing center and • a new amenities building which will include an onsite café, fitness center and meeting space to accommodate up to 750 attendees. While San Diego serves as the Company’s global headquarters, NuVasive remains committed to expanding its global footprint. The company recently opened its new international headquarters in Amsterdam, and finished a new 180,000 square foot manufacturing center in West Carrollton, Ohio. NuVasive’s footprint also includes a 100,000 square foot facility in Memphis, Tennessee, which serves at the Company’s central distribution hub. •
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Ethicon, part of the Johnson & Johnson Medical Devices Companies, has announced the U.S. launch of the ProxiSure Suturing Device, an advanced laparoscopic suturing device featuring Ethicon endomechanical, suture and curved needle technologies. Ethicon has been a steadfast champion of minimally-invasive surgery, delivering innovative solutions and support services that promote greater procedural expertise, improved hospital outcomes, and better patient care. The addition of ProxiSure™ builds upon Ethicon’s expansive portfolio of suturing technologies while establishing a new standard of excellence in laparoscopic suturing. ProxiSure Suturing Device features wrist-like maneuverability and curved needle in an advanced suturing device that improves suturing precision in tight spaces.1 The suturing precision is deployed by enabling surgeons to reach the desired angle, control bites, and secure knots, as well as to have maximum control of the needle during suturing and knot tying, which may reduce the risk of needle loss. “With the patient’s health at the forefront of our thinking, we aimed to introduce a suturing device that will help reduce the margin of error in minimally-invasive surgery,” said Dr. Niels-Derrek Schmitz, Franchise Medical Director for Ethicon. “Surgeons will now be able to have the same confidence in laparoscopic suturing that they have always had with traditional procedures using Ethicon products.” With a highly intuitive tissue repair experience, ProxiSure is designed to enable precise suturing in tight spaces and is well suited for bariatric, general, colorectal, and gynecology procedures. The device’s curved needle improves a surgeon’s ability to suture a variety of tissue layers, including flat surfaces. “Versatility is the key,” said Dr. Schmitz. “ProxiSure enables surgeons to do a wide range of tasks in the OR while maintaining an immensely user-friendly configuration.” Ethicon is the market leader in suture technology, consistently bringing cutting-edge products designed to enhance the surgeon’s experience, accelerate healing time and improve patient outcomes. As the latest surgical innovation, ProxiSure will deliver new value for customers. •
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INDUSTRY INSIGHTS NEWS & NOTES
AAAHC Names Noel M. Adachi as New President & CEO The Accreditation Association for Ambulatory Health Care (AAAHC) has announced the appointment of Noel M. Adachi, MBA, as president and chief executive officer, effective September 5. Adachi will maximize her expertise in medical innovation, growth management, and executive leadership in her new role with AAAHC. Adachi has spent 32 years in health care with a focus in medical device and association management, with more than 20 years in executive positions across a variety of departments including marketing, sales, strategic planning, and international business development. Within these roles, Adachi has been involved in key initiatives, helping to drive new product development, process improvements, IT system capability design, and website functionality. “Noel Adachi has the industry and leadership knowledge to drive growth and innovation while improving health care quality through effective accreditation,” said Kenneth M. Sadler, DDS, MPA, chair of the AAAHC Board. “Her experience in successfully building and sustaining new initiatives will be key for AAAHC as we launch into new areas of growth and development.” Adachi joins AAAHC after a 21-year tenure at the College of American Pathologists (CAP), where she was instrumental in
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OR TODAY | November 2017
driving growth in many key areas: quality improvement through accreditation, proficiency testing, education, and other clinically relevant performance measurement tools. When CAP expanded to international markets, Adachi took on the role of Vice President, International, where she substantially grew the CAP’s market presence to a profitable, and still-growing, adjunct to the organization’s already established U.S. base. “I am proud of my accomplishments as a ‘builder’ of new strategies, execution plans, and organizational reshaping efforts that have delivered accelerated, profitable growth to allow organizations to prosper,” said Adachi. “AAAHC is entering a critical time in development and opportunities, and I am confident in my abilities to help accelerate growth and innovation throughout the organization.” Adachi’s responsibilities at AAAHC also will include leading the Institute for Quality Improvement, the organization’s department founded to address the quality improvement requirements of AAAHC accreditation; and growing the AAAHC International division Acreditas Global. Adachi received an undergraduate degree in mathematics from Knox College in Galesburg, Illinois, and an MBA from Northwestern University’s J.L. Kellogg Graduate School of Management. •
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November 2017 | OR TODAY
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INDUSTRY INSIGHTS AAAHC UPDATE
BY MARY SIBULSKY AND BRIAN E. SZUMSKY
AAAHC TOOLKIT ADDRESSES
DISASTER PLANNING AND RISK ASSESSMENT
I
n August, over the span of one weekend, Hurricane Harvey poured more than two feet of water on Houston causing widespread flooding and power outages and damaging infrastructure and personal property. The National Weather Service called the situation “beyond anything experienced.” Similarly, in Florida, Hurricane Irma left millions without power and turned city streets into rivers. While natural disasters of this magnitude are not the norm, the importance of an effective disaster plan cannot be overstated. In health care, an ASC must meet the standards of accreditation or certification for CMS. But more importantly, a wellwritten and rehearsed plan could potentially save lives. So what does it take to create a plan that meets your facility’s needs and helps you to achieve accreditation standards? A good plan includes an overview of your facility and the various factors that will impact it in the event of a disaster.
STEP ONE: WHAT MAKES A DISASTER?
Not everyone understands that disasters are not limited to just well-known weather occurrences like hurricanes and flooding; they can also include events as simple as a minor plumbing leak – a “disaster” that might prevent the safe use of the operating rooms. So start your plan with a definition of what types of disasters could affect your organization. A good way to further breakdown this definition is by identifying internal and external disasters. Ask your staff members this question: “What occurrences would make working a severe hardship and potentially impact the care we provide?” You might be surprised to hear some of them refer 18
OR TODAY | November 2017
to the loss of phone service or medical records access as a disaster! STEP TWO: HAZARDS OR RISK ASSESSMENT
According to FEMA, “A risk assessment is a process to identify potential hazards and analyze what could happen if a hazard occurs. A Business Impact Analysis (BIA) is the process for determining the potential impacts resulting from the interruption of time-sensitive or critical business processes.” Make a list of the potential hazards or risks your facility could face. Then, assess the probability and severity of those risks. Once the risk assessment and
description are completed, an authority and communications chart should be created. This will include a list of who will be in charge and which employees will be asked to respond. When completing the roster, consider: • Assessing who is activated and their ability to respond • Compiling contact information, including cellphone and landline numbers • Creating an authority chart – Alternates [Staff member(s) designated to substitute for the primary contact in the event that person is unable to respond] • Creating a call list The call list is kept near the main phone area for your facility and tested periodically to verify contact information. A copy of the list should also be maintained offsite. Along with the internal contacts, a list of local/county and national resources should be created. This can include numbers or access information for: • Police, Fire, Paramedics • Building Management • Building Security • Telephone Company • Power and Gas • IT resources • Insurance Company • County Office of Emergency • Management OEM • City Street Department City Water Department • City sewer Back-up • FBI local office WWW.ORTODAY.COM
AAAHC UPDATE
• Poison control center • Medical gases suppliers • State police • Road conditions reports • National weather service CMS AND EMERGENCY PREPAREDNESS
CMS has new requirements for risk assessment that become effective November 2017. Emergency preparedness will be a new CoP/CfC. Per CMS, there are four core elements of the Emergency Preparedness Program (each element of the plan must be reviewed and updated annually). RISK ASSESSMENT AND PLANNING – all providers must develop
an emergency plan using all hazards approach; plan and identify in advance essential functions and who is responsible in a crisis. POLICIES AND PROCEDURES – P&Ps are developed based on the emergency plan and reviewed annually at a minimum (e.g. medical documentation, evacuation or shelter and place) COMMUNICATION PLAN – identify alternate means of communication, provide information to local authorities sharing medical information, occupancy information and ability to provide assistance to other facilities in the community. TRAINING AND TESTING PROGRAM – train staff on an annual and
as-needed basis and test the plan through drills. The plan is based on a documented risk assessment using an “all hazards” approach. An all-hazards approach is an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters, including internal emergencies and a manmade emergency (or both) or natural disaster. This approach is specific to the location of the provider or supplier and considers the particular type of hazards most likely to occur WWW.ORTODAY.COM
in their areas, e.g., hurricane, floods, earthquakes, etc. Facilities are expected to be in compliance with the requirements by November 15, 2017. The 2017/2018 Accreditation Handbook for Medicare Deemed Status Surveys will include the revised Physical Environment Checklist (PEC) from 2016 to reflect adoption of the 2012 editions of NFPA 99 and 101 by CMS and the new CMS requirements for emergency preparedness. PROTECTING THE ORGANIZATION
A comprehensive Disaster Plan includes an overview of the steps to be taken to protect the lives and assets of the organization. This can include a description of the disaster drill schedules; fire drill plans and policies; quality assurance meetings that review the facilities’ functions; education relevant to disaster awareness, such as OSHA training; security precautions; CPR classes; emergency back-up equipment in the building and how it is tested; availability of shelter-in-place plans; and the equipment needed to secure the building. If staff members are allowed time to participate in outside preparedness training programs, such as those available through FEMA, the Medical Reserve Corps, or online training, this should also be included. For a contingency such as mass illness in either employees or staff, you will need to put in place an Emergency Pandemic Plan. Assistance creating a good pandemic plan is available from the CDC at emergency.cdc.gov/planning/. ADDITIONAL PLAN COMPONENTS
The disaster plan and drills need to have an evacuation plan in place that includes more than one location for assembly to cover all potential events. An annual disaster drill should allow practice for staff members to assemble at the evacuation point, and there should be a prior discussion about what equipment will be required during an evacua-
tion. Hands-on practice with evacuation equipment, such as emergency patient slides or transport materials, should occur regularly. Communicating your disaster plan with local, county and state authorities allows them to provide input regarding the details of your plan. Knowing what your emergency response plans are may be vital to the strength of your community’s emergency responders in times of disaster. No plan is complete without giving serious thought to what will occur AFTER the disaster occurs. Putting a business back together and dealing with the psychological impact of severe disasters requires planning and compassion for the effect that a disaster may have on staff and the business clients served. Training in critical incident debriefing can be very helpful in getting the organization back on track. Assessing the plan to accreditation standards and Medicare guidelines is critical and should be undertaken at least annually. Lastly, all staff needs to be educated in the plan’s use, location, and implementation. A plan is only paper if the information in it isn’t disseminated to those impacted by the plan. Just as we regularly rehearse for cardiac emergencies to feel competent and prepared, disasters require the staff to feel well trained and ready to respond. Mary Sibulsky is Nurse Manager of an Ophthalmic ASC in North Idaho and has been a nurse since 1975. She is actively involved the Medical Reserve Corps and was selected as part of the Federal Cadre team specially trained to respond to national emergencies. She has worked as an ASC Surveyor for AAAHC since 2007. Brian E. Szumsky is the communications project manager within the AAAHC Marketing and Communication department. He has been with the company since 2015 and has worked with the consulting arm (Healthcare Consultants International) and the AAAHC Institute for Quality Improvement. November 2017 | OR TODAY
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SCRAPBOOK OR TODAY LIVE!
STAFF REPORTS
OR TODAY LIVE
CONTINUES TO IMPRESS
T
he 2017 OR Today Live Surgical Conference drew about 100 perioperative and surgical professionals from throughout the United States. Attendees and exhibitors raved about the quality of the continuing education and the near-perfect networking opportunities available at planned events as well as interactions that happened organically during the conference. “The educational line-up for this year’s OR Today Live conference far exceeded our expectations,” MD Publishing Vice President Kristin Leavoy said. “The speakers received rave reviews from attendees as they commented on the quality of the presentations, the valuable information provided, and the sharing of steps
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to implement improved practices at their facilities.” “Vendors complimented OR Today Live on giving them the opportunity to connect one-on-one with attendees, not just in the exhibit hall, but in the sessions and networking events as well,” Leavoy added. When asked to describe her favorite part of OR Today Live MaryJo VanSant of Reading Hospital in Pennsylvania said “The best part is that it’s so intimate and smaller than other huge conferences I’ve been to.” “As a new nurse manager, I find I’m really enjoying the classes that focus on the collaboration between the OR and SPD,” she added.
For more information about the OR Today Live Surgical Conference, including archived educational presentations and information about the 2018 event, visit ORTodayLive.com.
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SCRAPBOOK
1. Keynote presenter, David Taylor MSN, RN, CNOR compares notes between educational sessions. 2 Attendees at OR TODAY Live! pause to pose with this year's show guide. 3. MD Publishing President, John Krieg and Jeff Taltavull of AIV, Inc are pleased to be posted up in the exhibit hall.
6. Whether you bring a friend along or meet a new friend, OR TODAY Live! offers great moments to catch up! 7. Dawn Whiteside MSN, RN, CNOR, RFNA had a packed room of eager attendees for her session.
8. United States Navy Nurse Corps welcomed attendees at their booth in the exhibit hall. 9. Attendees were captivated by the keynote presentation, where David Taylor discussed leadership in the health care environment.
4. The very talented, Nashville-based singersongwriter, Lexi Hayden entertained attendees during Mondays dinner. 5. There's no lack of discussion amongst attendees after a great day of informative, thought-provoking sessions.
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INDUSTRY INSIGHTS ASCA UPDATE
BY WILLIAM PRENTICE
ASCA COMMENTS ON
MEDICARE’S 2018 PROPOSED ASC PAYMENT RULE
I
n early September, ASCA submitted formal comments to the Centers for Medicare & Medicaid Services (CMS) on Medicare’s proposed 2018 ASC payment rule. In addition to suggesting reimbursement rates for the procedures ASCs will provide to Medicare beneficiaries next year, the proposed rule suggests new Medicare payment policies. These include new quality reporting requirements for ASCs that would take effect next year and later. Once CMS considers all the comments it receives on its proposed payment rates and policies, it will issue a final rule. That rule will establish 2018 payments and is due out by November 1 this year. Key recommendations ASCA made to CMS in its comments this year include the following: CMS should replace the Consumer Price Index for All Urban Consumers (CPI-U) with the hospital market basket as the annual update mechanism for ASC payments. ASCA continues to point out that the CPI-U is not a suitable inflation index to use to update ASC payments because it does not accurately reflect the costs borne by ASCs and others that provide surgical procedures. Only approximately 8.5 percent of the index’s inputs track anything having to do with health care, and even those inputs track a consumer’s experience purchasing health care items, rather than a provider’s experience purchasing the items necessary to furnish a health care service. Medicare’s payments to hospital outpatient departments (HOPDs) are updated each year based on the hospital market basket. The market basket index reflects the cost of items and services needed to furnish an outpatient surgical procedure, such as compensation, utilities, labor-related services and non-labor related services. Since 22
OR TODAY | November 2017
the annual increases in the cost of doing business in an HOPD – equipment, devices, implants, facility upkeep and staffing costs – are comparable in ASCs, ASCA continues to ask that ASC payments be updated each year using that same measure. CMS should eliminate the secondary rescaling adjustment that is applied to the ASC relative weights. CMS applies an additional scaling factor to the ASC weights that is intended to maintain budget neutrality within the payment system; however, a consequence of this scaling is ever-increasing payment differentials between ASC and HOPD payments. There is no evidence of growing differences in capital and operating costs in the two settings to support this growing payment differential. By applying ASC-specific adjustments like the scalar, CMS is exacerbating the gap between HOPD and ASC rates. In so doing, the agency is needlessly increasing program costs by making it financially untenable for ASCs to perform many procedures that are otherwise clinically appropriate. In the process, CMS is encouraging physicians
and hospitals to furnish those procedures in the more expensive HOPD setting. To ensure that ASCs remain a viable alternative for Medicare beneficiaries, ASCA continues to recommend that CMS discontinue use of the ASC relative weight scalar. CMS should reimburse ASCs for all the same surgical codes for which it reimburses HOPDs. In its proposed rule, CMS proposes to add three new procedures – 22856 (Cerv artific diskectomy), 22858 (Second level cer diskectomy) and 58572 (Tlh uterus over 250 g) – to the ASC list of payable procedures for 2018. ASCA pointed out that second level spine codes, such as CPT 22858, come with significant additional costs, including increased operating room and staff time. Therefore, CMS will not see volume migrate out of the inpatient setting and into the ASC without providing adequate reimbursement for this code. ASCA also indicated that it would appreciate an opportunity to further discuss with CMS officials how the decision to package this and other codes together has negatively impacted the migration of procedures to the outpatient setting. WWW.ORTODAY.COM
ASCA UPDATE
ASCA noted that it appreciates that CMS has acknowledged that these procedures are safe and effective when done in the ASC setting but remains concerned that the agency continues to reimburse HOPDs for providing hundreds of other codes that it will not cover in ASCs. Specifically, there are 345 surgical CPT codes that are separately payable in the HOPD but not in the ASC. These procedures are designated as Surgical Procedures Excluded from Payment in ASCs, but are not included on the inpatient-only (IPO) list. Surgeons in ASCs are already performing these procedures safely on non-Medicare patients. With technological advances increasingly driving procedures from the inpatient to the outpatient setting, ASCA urged the agency to leverage the high-quality, cost-effective care that ASCs provide by reforming its current policy. Since the survey and certification requirements are essentially the same in ASCs and HOPDs, ASCA pointed out, the primary difference between them is simply the payment rate assigned to each facility type. There is no credible safety argument to justify the expansive list of codes that are reimbursable in HOPDs but not ASCs. Therefore, ASCA requested that CMS simply maintain an IPO list and allow all other surgical codes to be performed in either an HOPD or an ASC. CMS should remove total knee arthroplasty (TKA), partial hip arthroplasty (PHA) and total hip arthroplasty (THA) from the Medicare inpatientonly list and add these codes to the ASC-payable list. These procedures are currently being done safely and effectively on appropriate patient populations in ASCs. CMS uses five criteria when reviewing procedures to determine whether they should be removed from the IPO list and assigned to an Ambulatory Payment Classification (APC) group for payment under the Hospital Outpatient Prospective Payment System when provided in the hospital outpatient setting. While CMS WWW.ORTODAY.COM
notes that a procedure is not required to meet all the established criteria to be removed from the IPO list, ASCA noted that TKA, PHA and THA do meet all the criteria and should all be removed from the IPO list. ASCA also indicated that it believes CMS made its decision to propose removal of TKA from the IPO list in 2018 based on staff’s belief that the code meets these five criteria, and since the hip arthroplasty codes meet the same criteria, they should also be removed from the IPO list. CMS should lower the deviceintensive threshold to encourage migration of services to the ASC setting. CMS classifies codes with high, fixed device costs as “device-intensive codes,” which are currently defined as those procedures that have a device offset greater than 40 percent of the mean cost of the procedure when provided in the HOPD setting. When ASC services have device costs that are less than 40 percent of the overall cost in the HOPD setting, the conversion factor is applied to the entire relative weight for the service, effectively discounting the payment for the device by more than 40 percent over what is paid to the HOPD. Since an ASC’s nondevice reimbursement is approximately 53.5 percent of that in the HOPD setting, ASCA recommended that CMS should lower the 40 percent threshold to 30 percent to allow for ASCs to perform more procedures with substantial device costs and encourage migration of these codes to the ASC setting. ASCA supports the proposed delay of the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery (OAS CAHPS) Survey. CMS cited its desire to “appropriately account for the burden associated with administering the survey in the outpatient setting of care” as one reason for delaying mandatory implementation of the OAS CAHPS survey and the five ASC Quality Reporting (ASCQR) program measures based on this survey. ASCA appreciates this reconsideration, and supports
delaying mandatory implementation of the survey until it is shortened and an electronic option becomes available. Both developments would significantly reduce the cost and administrative burden to ASCs and make the survey easier for patients to complete. NEW QUALITY REPORTING MEASURES
CMS proposed to add several new measures to the ASCQR program. It proposed to adopt ASC-16: Toxic Anterior Segment Syndrome (TASS) for CY 2021 payment determination and subsequent years. ASCA supported the inclusion of this measure in the ASCQR Program. CMS also proposed two new measures for CY 2022 payment determination and subsequent years: ASC-17: Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures and ASC-18: Hospital Visits after Urology Ambulatory Surgical Center Procedures. While ASCA supports quality reporting, it continues to be concerned with these types of all-cause measures that rely on a retrospective analysis of claims over an extended period. As with current measure ASC-12: Facility Seven-Day Risk Standardized Hospital Visit Rate after Outpatient Colonoscopy, ASCA pointed out, measure scores and results will not be received until months after the patient’s visit, significantly limiting the usefulness of the information. CMS also has invited public comment on the Ambulatory Breast Procedure Surgical Site Infection Outcome measure (NQF #3025) for potential inclusion in the ASCQR Program in future rulemaking. ASCA supported the inclusion of this measure in the ASCQR Program. For more information, please write Kara Newbury at knewbury@ascassociation.org. William Prentice, is the Chief Executive Officer of the Ambulatory Surgery Center Association.
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IN THE OR SUITE TALK
STAFF REPORTS
SUITE TALK
Conversations from the OR Nation’s Listser
EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) Is there a safe limit to the number of Extracorporeal Shock Wave Lithotripsy (ESWL) procedures that can be done in a day? Some facilities have an ESWL machine brought in for procedures, and the operator/driver of the machine can only work so many hours and be driving for so many hours without being considered unsafe. Are there any small facilities that have run into this dilemma? The surgeons always want to schedule as many as they can, then they take longer than expected, and it can lead to a very long day for the operator/driver. A: We are a small facility and do up to five per day. We have not run into any issues. A: No issues here with “over service” hours
A: I have never had that problem and we did ESWLs one day per week and all the urologists scheduled on that day so we did more than five.
DISCHARGING WITH A TAXI Is it acceptable to allow a patient that has received general anesthesia to be discharged with a Uber or taxi as their means of transportation to home? A: Not without a responsible adult, according to The Joint Commission. It has been a challenge for the last several years for us as docs want to be able to do it. Get your underwriters to comment on it and a copy of The Joint Commission regulations to show the folks who think it is OK.
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A: Only if they have a responsible adult with them, in addition to the taxi driver. A: No. A: We only allow if they have a responsible party accompanying them in the taxi.
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SUITE TALK
A: I think that could get you in trouble. A: Although it is not ideal, we have discharged patients home in a taxi but require a surgeon order in writing. A: I assume you mean alone in a taxi. If so, then no that would not be acceptable in my opinion. Post general anesthesia discharge would require someone to take responsibility for being with the patient for the first 24 hours after same-day surgery. Of course, the patient and the designated care provider can go home in a taxi, but the patient should not be discharged alone. In the past, we usually insured that prior to surgery. If they showed up alone, we would make sure that someone was picking them up and going to stay with them. On several occasions we cancelled surgery for this reason and if we could not cancel surgery then we admitted them overnight. 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 REPORTS
MARKET ANALYSIS ENDOSCOPES
P
hysicians use endoscopes multiple times to diagnose and treat various diseases. Endoscopes are used on a number of patients, making them prone to contamination after use. To avoid risk of infection, endoscopes need to be sterilized before use. Automated endoscope reprocessor devices are used to clean, sterilize and disinfect endoscopes. “The global automated endoscope reprocessors market estimated to be worth $740.6 million in 2015, is expected to increase at a compound annual growth rate (CAGR) of 7.2 percent through 2024,” according to Persistence Market Research. “Increasing adoption of automated endoscope reprocessors in hospitals for infection control and prevention is expected to fuel revenue growth of the global automated endoscope reprocessors market over the forecast period (2016-2024). An increasing number of endoscopy procedures coupled with minimally invasive surgeries among a rising global population is further expected to drive demand for the adoption of automated endoscope reprocessors,” according to Persistence Market Research. “Rising concerns pertaining to patient safety, strong health care infrastructure support, and well-established reimbursements for surgical procedures are also driving revenue growth of the global automated endoscope reprocessors market.” WWW.ORTODAY.COM
Yet, the report did indicate hurdles that the market will have to overcome. “However, risk of infection after endoscopic reprocessing procedures and complications associ-
“The global automated endoscope reprocessors market estimated to be worth $740.6 million in 2015.” ated with automated endoscope reprocessors are some of the challenges likely to hamper the growth of the global automated endoscope reprocessors market over the forecast period,” according to Persistence Market Research. The cleaning of endoscopes is also driving other global markets. “The global endoscope repro-
cessing solution market is anticipated to show robust growth owing to increased investment in research and development by key players,” according to a report by LANEWS.org. “Hospitals are anticipated to show high growth owing to increased percentage of endoscopic procedures in hospitals and availability of skilled staff,” the report added. Endoscope cleaning is a part of the larger medical device cleaning market. According to a new Data Bridge Market Research market report, the global medical device cleaning market accounted to $1.54 billion in 2016 and is expected to expand at a CAGR of 5.3 percent during the forecast period of 2017 to 2024. “The rise in the global medical device cleaning market is owing to rapid increase in geriatric population and rise in incidence of hospital-acquired infections (HAIs) and chronic diseases,” Data Bridge Market Research reports. “North America holds the largest share of this market because of its well-developed health care industries and rise in surgical treatments,” the report adds. “AsiaPacific is expected to witness the highest CAGR in the forecast period due to health care spending and reforms along with growing awareness, low labor costs, and favorable regulatory environment.”
November 2017 | OR TODAY
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IN THE OR PRODUCT FOCUS
3M CLEAN-TRACE ATP MONITORING SYSTEM The 3M Clean-Trace ATP Monitoring System is made up of the 3M Clean-Trace Luminometer LX25 and the 3M Quality Control Data Manager, which together provide real-time, quantitative data and reporting on endoscope and surgical instrument reprocessing, as well as for high-touch surfaces in patient care. The Luminometer LX25 is designed for accuracy, consistency and user friendliness with a color touchscreen and a modern ergonomic design. It measures within 10 seconds, displays and records the results, and transmits them wirelessly to the Quality Control Data Manager. The data is then analyzed and translated into intuitive dashboards and reports for easy analysis. For more information, please visit 3M.com/CleaningMonitoring. •
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OR TODAY | November 2017
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PRODUCT FOCUS
EVOTECH ECR ADVANCED STERILIZATION PRODUCTS (ASP) Does not eliminate bedside cleaning and may not eliminate manual cleaning; health care facilities should follow their own policies and procedures related to the reprocessing of endoscopes to ensure they are complying with all steps recommended by the device manufacturers and are consistent with current standards and guidelines. Not all endoscopes can be automatically cleaned, but may be high-level disinfected. It is recommended that endoscopes with open/closed elevator wire channels be manually cleaned as per manufacturer’s instructions in addition to using the cleaning cycle of the EVOTECH System. Please refer to the EVOTECH ECR User Guide and specific connection diagrams for more detailed information regarding cycle capabilities. •
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November 2017 | OR TODAY
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IN THE OR PRODUCT FOCUS
CYGNUS AIRTIME FLEXIBLE SCOPE DRYER The Airtime Flexible Scope Dryer uses filtered air to dry the air/water and suction channels after automated reprocessing. The Airtime dryer ensures scopes are not stored or put into immediate use with wet channels. Studies indicate there is a strong correlation between moisture and microbe colonization within flexible endoscopes. Properly drying channels reduces the risk of infection. Airtime dries two scopes simultaneously. The dual screen allows for two scopes to be dried with independent start and stop times. Restricted channel sensors will immediately shutoff the Airtime pump and alert the user to a potential clogged channel. •
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OR TODAY | November 2017
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PRODUCT FOCUS
HEALTHMARK FLEXIBLE INSPECTION SCOPE Healthmark has announced the newest addition of the Flexible Inspection Scope (FIS-003) to its Prosys Optical Inspection line of products. The FIS-003 features a longer 110cm flexible shaft with graduation marks. Like other flexible inspection scopes it also includes a distal tip composed of a light source and camera lens at the end of the flexible shaft. Designed for instruments 2.4mm in diameter or larger, inspection is now easier on the interior of instruments with small diameters, including many flexible GI endoscopes. The camera and light are powered by the USB connection on a PC. Compatible with Windows 7, 8 and 10, the included software allows viewing and recording from most computers. Paired with the optional Flex Arm, the Flexible Inspection Scope can be securely fastened to workstations to free both hands for manipulation of the scope and the target medical device. It is the perfect tool to visually inspect lumened medical devices after cleaning. •
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November 2017 | OR TODAY
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IN THE OR PRODUCT FOCUS
OLYMPUS OER-PRO The OER-Pro is designed to save time and space while improving efficiency for endoscope reprocessing. With 99 percent uptime, the OER-Pro simultaneously reprocesses two flexible endoscopes in less than 30 minutes, delivering automatic highlevel disinfection, alcohol flushing and air purging of channels. The RFID management system automatically records scope serial and model numbers, operator ID, and time of reprocessing, freeing staff from manual input of data. Additionally, the 18 inch wide footprint allows for maximize use of space in the reprocessing room. For information on the OER-Pro, visit medical.olympusamerica.com/reprocessing. •
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OR TODAY | November 2017
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PRODUCT FOCUS
RUHOF SCOPEVALET INSTRUFLUSH ScopeValet InstruFlush is an effective instrument and scope channel/lumen pre-cleaning and flushing device, which increases the productivity of syringe flushing by 74.9 percent. The InstruFlush provides a pulse feature for hard-to-dislodge soils and works very well with low-foaming enzymatic chemistries, detergents and alcohols. Used with or without the ScopeValet InstruStation (mobile sink insert), the pump can be wall mounted, placed on a countertop or easily adapted to a facility’s existing sink via a sink accessory rail. The ScopeValet InstruFlush consistently meets ANSI/AAMI ST79: 2010 recommendations for cleaning, flushing and rinsing and offers components that facilitate compliance to cleaning solution and medical device manufacturers’ IFUs. The product greatly reduces the risk of repetitive motion injuries and frees up the technician to perform other tasks. •
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November 2017 | OR TODAY
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November 2017 | OR TODAY
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IN THE OR CONTINUING EDUCATION CE510G
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OR TODAY | November 2017
BY MAUREEN HABEL, MA, RN, AND CATHERINE E. JORDAN, MSA, RN, LNCC
WWW.ORTODAY.COM
CONTINUING EDUCATION CE510G
DOCUMENT IT RIGHT WOULD YOUR CHARTING STAND UP TO SCRUTINY?
F
rom the first day of nursing school until graduation, students learn the importance of documentation. In practice, however, nurses can find themselves too busy, tired, or uncertain about what to chart. In these litigious times, nurses should think carefully about what a jury would decide when looking at their documentation if a patient claims that his or her injury is due to their negligence.1
OnCourse Learning guarantees this educational activity is free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See page 43 to learn how to earn CE credit for this module.
Goal and objectives
The purpose of this program is to provide nurses with information about the value of laws and standards governing nursing documentation, legal basics for appropriate documentation, and strategies for documenting changes in a patient’s condition. After studying the information presented here, you will be able to: •P rovide the legal definition of nursing negligence •D escribe four characteristics of legally credible charting •D escribe two charting practices that can lead to legal problems
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Your patient’s chart is a legal document that describes all of his or her interactions with you and other caregivers. Your documentation must provide a complete and accurate accounting of his or her condition and the care you provided.2 If you are asked to testify in a legal action, you may need to recall details that occurred months or even years ago. Without a complete, accurate, and legible medical record, you may be unable to defend yourself against allegations of improper care. Your documentation can discourage a plaintiff from pursuing a legal claim or can provide the fuel for a lawsuit.3,4 Most lawsuits involving nurses are civil cases that attempt to prove that a nurse’s negligent care resulted in injury to a patient. The law defines negligence as failure to provide a patient with the standard of care that a reasonably prudent nurse would exercise under the same or similar circumstances.5,6 To prove that a nurse was negligent, the patient’s attorney must prove these four elements: • Duty. T he duty is usually established when the nurse
agrees to provide care to the patient and to follow an acceptable standard of care. • Breach of duty. A breach of the duty is a negligent departure from the established standards of care. It is the failure to do what a reasonable prudent nurse would do in the same or similar circumstances. • Causation. Causation is the apparent relationship between the breach of the duty and the harm or injury to the patient. A nursing negligence cause of action requires proof that the failure of the care was the immediate cause of the injuries. • Damages. Damages occur when the patient suffered physical or psychological injuries.5,6 If you face an allegation of negligence or improper conduct, your documentation can make or break your case. Your contention that you provided appropriate care is significantly weakened if you didn’t November 2017 | OR TODAY
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IN THE OR CONTINUING EDUCATION CE510G document or if your documentation doesn’t clearly show that you met the standard of care. Without such documented evidence in the medical record, you must rely on your ability as a witness to convince a judge or jury that you provided appropriate care despite your failure to document the care you provided.5 Charting errors and omissions are a significant source of liability risk for nurses. During a trial, the patient’s attorney will use documentation to try to prove that the standard of care wasn’t met. A complete and accurate medical record is crucial because appropriate documentation provides evidence that you met the standard of care.6 LAWS AND STANDARDS
The type of nursing information that appears in a medical record is determined by standards developed over the years by state laws, the nursing profession, and accrediting organizations such as The Joint Commission. The U.S. legal system has helped nurses know what must be included to conclude that patient care documentation is accurate and appropriate.6 Each state has enacted a nurse practice act that authorizes an individual to practice as a registered nurse if the applicant meets specific criteria. Laws or administrative rules in each state further outline documentation issues, such as handling of records, falsification of records, and confidentiality.6,7 Regardless of your work setting or nursing specialty, you must document care based upon the requirements of your state’s nurse practice act. For information on your state’s nurse practice act, contact the National Council of State Boards of Nursing. Documentation principles apply to all charting systems and formats.8 In addition to observing laws governing documentation, you must adhere to professional standards, such 38
OR TODAY | November 2017
as those established by the American Nurses Association.6,7 If you practice in a nursing specialty area, you must be familiar with and demonstrate adherence to documentation standards developed by your specialty organization. The commission publishes widely accepted professional and documentation standards. Although The Joint Commission doesn’t mandate a particular format for documentation, it does require each healthcare facility being accredited to adopt a format that conforms to Joint Commission standards.1,3 The ANA’s and The Joint Commission’s standards are much more stringent than state laws. ANA standards of nursing practice require that documentation be based on the nursing process and that it should be ongoing and accessible to all members of the healthcare team.1,3 Because ANA standards reflect a national practice consensus, they carry a great deal of weight in court.1,3,6 You also must follow documentation policies as established by your employing facility. Most healthcare facilities develop their internal documentation policies and procedures based on state law, professional nursing standards, and Joint Commission requirements. For example, your facility’s documentation policies should identify how often documentation should be done, which staff members are responsible for charting in each part of a patient’s record, and what charting techniques and procedures are acceptable.4,6 However, if your facility’s standards are less strict than those of your nurse practice act, you must adhere to the higher standard of your state’s nurse practice act.6,7 EFFECTIVE DOCUMENTATION
Certain legal basics form a foundation for effective documentation. The saying “If it wasn’t documented, it
wasn’t done” is as valuable today as it was when you learned it in nursing school. In addition to organizing your documentation based on the five steps of the nursing process — assessment, planning, nursing diagnosis, interventions, and evaluation — your charting should leave no question in a future reader’s mind that you continuously assessed your patient’s condition and carefully monitored his or her progress. Nursing documentation that contains misspelled words or grammatical errors can lead lawyers and jurors to conclude that the nurse is uneducated or careless.3,5 The following examples of legal cases emphasize the importance of nursing documentation. In one case, the court ruled in favor of a patient who ended up with a belowthe-knee amputation resulting from a decubitus ulcer that originated on the patient’s heel. At the time of admission to a skilled nursing facility, nursing had documented breakdown on the patient’s sacrum. At the time of discharge to home health, one month later, nursing again documented the breakdown on the patient’s sacrum. There was no documentation of breakdown on the patient’s heel throughout her stay at the skilled nursing facility. The home health nurse found the heel decubiti at the time of intake for services. At the trial, nursing attempted a case for documentation by exception. The decubitus was not documented, therefore, it did not exist during the patient’s admission to the skilled nursing facility. This approach was turned down by the courts and the court ruled in favor of the patient.9 A pending case in Louisiana, alleges a home health nurse is responsible for her patient’s renal failure due to toxic vancomycin blood levels. The home health nurse failed to draw vancomycin peak and trough WWW.ORTODAY.COM
CONTINUING EDUCATION CE510G
Sources of Documentation Standards • State nurse practice act and administrative code or rules
• National professional standards
• Specialty nursing organization standards
• Joint Commission standards • Standards of your employing facility
blood samples for drug level monitoring. The dose of vancomycin prescribed for the patient became too much for his kidneys to filter, yet the patient’s physician would not know to change the dosing because there were not any drug levels drawn. The negligence of this nurses, is allegedly responsible for the permanent damage to the patient’s kidneys.10 In a separate court case, a jury returned a defense verdict for a hospital based on complete and accurate nursing assessment of a patient’s fall risk and steps taken to prevent a fall.11 Recently, the court found for the plaintiff after a patient in a nursing home died of dehydration. Nurses in this case failed to document the patient’s continuing diarrhea and steady weight loss. A month before the patient’s death, a nurse had documented poor skin turgor; however, no further assessment or follow-up was documented.12 To help ensure legal credibility, make sure your charting is timely, accurate, truthful, and appropriate. Timely documentation means documenting care as soon as possible after it’s provided. Although charting intervals will vary depending on the healthcare setting, regular charting entries demonstrate that you are WWW.ORTODAY.COM
checking your patient’s condition frequently.6 Don’t wait until the end of your shift to document, when you may not recall important details or may eliminate potentially important information because you’re pressed for time. Accurate documentation means that you document the facts about patient care. Chart only what you see, hear, smell, or feel. Document only the care that you personally provided. Depending on your facility’s policy, document only care provided by an unlicensed assistive staff member that you have directly observed or evaluated. Write specific, accurate descriptions. For example, charting “Bright red blood 18 cm in diameter on bed linens” is much more specific than charting “Bed soaked with blood.”6 Don’t use meaningless expressions such as “patient had a good night” or “appears” or “seems.” Follow your agency’s policy when using abbreviations. If unsure about standard abbreviations used by your facility, spell it out. Abbreviations on The Joint Commission’s official “Do Not Use” list should be avoided.3 Truthful documentation means avoiding assumptions and documenting only what you have actually observed. Appropriate documentation refers to committing to writing in a patient’s chart only statements you’d be comfortable showing in public.4,6 Make sure you follow your facility’s documentation policies about issues such as late entries, legible charting, record confidentiality, blank lines, approved abbreviations, cosigning, and patient refusal of treatment. Be sure to document any safety precautions you implement, such as putting up side rails. Keep comments about other staff members, allegations of inadequate care, or references to staffing problems out of the pa-
tient’s medical record. Issues such as these found in a patient’s chart can be a red flag to lawyers and jurors.3 Once litigation has begun, you shouldn’t add information to a patient’s medical record. The patient’s attorney can use handwriting experts to determine the time at which various entries were made. If you suspect that another healthcare professional has made illegal changes to a patient’s chart, notify your nursing supervisor. Never change your notes if requested to do so by a colleague.6 Evidence of tampering with a patient’s chart not only is illegal, but it can cause the entire medical record to be inadmissible as evidence in court.6 The sidebar “Examples of Illegal Tampering With Medical Records” shows examples of illegal tampering or alterations to the medical record. You also may be subject to charges of falsification of records and fraud if you document care that hasn’t been provided. Charting medication administration, dressing changes, or other treatments in advance all constitute falsification of records.6 The
Examples of Illegal Tampering With Medical Records6 • Adding to another person’s note
• Destroying the patient’s chart • Not recording important details
• Recording false information • Writing an inaccurate date or time
• Adding to previous notes
without indicating that the note is a late entry
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IN THE OR CONTINUING EDUCATION CE510G only component of the nursing process that may be documented before it is done is the plan of care. All other observations and activities must be charted only after you access or evaluate the patient or implement an intervention.1,3,6 When you write your initials on a medication record, your initials indicate that the medication has been given, not just removed from the drawer. If you place your initials on the record before giving the patient the medication, you are exposing yourself to legal risk. If your facility uses a charting by exception format, you’ll need to take extra precautions.6,13 In a CBE system, only exceptions to expected observations are charted. Because it may be several years before a lawsuit occurs, CBE may make it difficult to demonstrate that you provided appropriate care, especially if a patient develops complications. Because minimizing documentation makes it difficult to provide details, you’ll need to use well-designed flow sheets in a CBE system. If the CBE documentation doesn’t give a clear, accurate description of the patient’s condition, write it out in a narrative note. If you’re asked to testify several years later, you’ll be able to reconstruct an accurate picture of your patient’s condition.6,13 Although the CBE system saves valuable time, legal experts advise institutions to develop their system carefully and to use quality controls to ensure the system is working successfully.6 Certain types of charting actually increase your legal risk, such as failing to clearly describe situations that are out of the ordinary.6,14 Another documentation practice that increases risk is expressing a negative view or animosity toward a patient. Describing a patient’s behavior as uncooperative, difficult, or manipulative, or referring to the patient in a sarcastic manner alerts the pa40 OR TODAY | November 2017
tient’s lawyers that a nurse did not respect or value the patient.14 Although using a negative label when referring to a patient may reflect a nurse’s frustration, think of the impact of a negative term written in a chart projected on a screen in a courtroom. You should describe patients’ behaviors in a factual and impartial manner.
Documenting in Emergencies6,7 Make sure your documentation addresses these issues:
• The patient’s condition before the emergency
• The patient’s condition when the emergency began
CRITICAL INCIDENTS
Critical incidents often are the basis for legal actions against nurses and hospitals. In many instances, the precipitating event that results in a lawsuit is poor communication and documentation.14 Documenting care as you provide it is especially important when you’re charting in an emergency. If possible, ask another nurse to record events as they occur during the emergency. If you don’t have a recorder, keep a running log of notes rather than trying to rely on your memory to reconstruct events after the emergency. (See “Documenting in Emergencies.”) You place yourself at great legal risk when you don’t assess or monitor patients regularly or when you don’t report a significant change in a patient’s condition. Common occurrences in which nurses have been held liable for failure to observe and report include situations in which a patient’s condition undergoes a rapid change, such as after surgery or during labor, after the patient has suffered an injury while in the facility, and when the patient has known self-destructive tendencies.6 Accusations of failure to adequately observe and monitor can be substantially countered by accurate, detailed documentation.6 Numerous legal cases involve a nurse’s failure to notify the physician about changes in a patient’s condition. These cases often are
• When the emergency occurred
• When the physician was notified
• What interventions were used and when they were started
• How the patient responded to the interventions
extremely serious, resulting in death or permanent disability.6 As a nurse, you have a duty to intervene on your patient’s behalf. Frequently, your intervention consists of contacting the physician about a change in the patient’s condition and carrying out whatever therapy the physician prescribes. However, your legal obligation as a patient advocate goes beyond carrying out prescribed treatment. If, in your professional judgment, you consider physician orders to place a patient in jeopardy, you must intervene on behalf of the patient and clarify the treatment plan with the physician.4,6 Some recent malpractice cases have hinged on whether the nurse was persistent enough in an attempt to notify the physician or to convince him or her of the seriousness of the situation. Nurses who fail to continue to question inappropriate orders by contacting a nursing supervisor or going up the chain of command can be held liable for failure to intervene because the intervenWWW.ORTODAY.COM
CONTINUING EDUCATION CE510G
tion was below what is expected of them as patient advocates.6 If a change in a patient’s status warrants notifying the physician and a potential change in the treatment plan, you must be able to communicate essential information in a clear and logical manner that expedites understanding and intervention.1,3,6 Communication is more difficult by telephone than in person because nonverbal cues that enhance communication are eliminated. Therefore, when communicating via telephone, you must communicate information in a logical and organized way that creates a “word picture” for the physician.14 On weekends or on second or third shifts, your communication may be with an on-call physician instead of the patient’s primary physician. As this individual may not be familiar with the patient, you must summarize the patient’s background clearly before describing the problem.14 The sidebar “Organizing Your Reporting Data” outlines a way of organizing data before physician contact. Don’t apologize for calling the physician, and don’t make him or her guess what you really mean. Some nurse experts report that there is evidence that nurses continue to use indirect communication and defer to physicians in order to avoid conflict.15 You must be clear about why you’ve called rather than giving the physician a list of findings for him or her to interpret.6 Document each time you phone a physician, even if you don’t get through to him or her.6 When you do talk to the physician, chart the details of your message and the physician’s response.4,6 Be sure to document the name of the physician to whom you spoke. If you believe the physician is not responding appropriately, you’ll need additional documentation as a legal safeguard.4,6 WWW.ORTODAY.COM
Note specifically the details you reported, the time you called, the time new orders or no orders were received, and additional actions you take.4 If you don’t note the time you called, allegations could be made later that you failed to obtain timely medical treatment for the patient. Always note in the chart the specific change in the patient’s condition or diagnostic test result that prompted your call to the physician. If you’re reporting a crucial lab result, such as a high glucose level, but don’t receive an order for intervention, be sure to verify with the physician that he or she doesn’t want to give an order. Your charting should note: “Dr. Green notified of blood glucose of 220 mg. No orders received.” Reducing your legal risk is important in today’s healthcare climate, in which patients are sicker and more likely to have poor outcomes. Documentation that reflects the nursing process, including competent assessment, frequent observation, timely and accurate reporting, and the use of the chain of command, if necessary, often will protect the nurse from accusations of negligence — even when there is a poor outcome.14 Your documentation should tell a story. Your patient’s medical record and what you’ve documented in it is the single most important tool available to a nurse facing a charge of negligence.3 Legally credible documentation provides an accurate written record of the care your patient received and evidence that you met an acceptable standard of care. It tells anyone who reads it that you did all you were expected to do.4,6 By being familiar with your state’s nurse practice act, following professional standards for documentation, and adhering to your facility’s policies and procedures, you can provide your patient with quality nursing
care while protecting yourself and your employer from legal action. Maureen Habel, MA, RN, is an awardwinning nurse author residing in Seal Beach, California. Catherine E. Jordan, MSA, RN, LNCC, is a senior consultant at VantagePoint HealthCare Advisors in Hamden, Conn. REFERENCES 1. Ferrell KG. Documentation, part 2: the best evidence of care. Complete and accurate charting can be crucial to exonerating nurses in civil lawsuits. Am J Nurse. 2007;107(7):61-64. 2. Austin S. Ladies & gentlemen of the jury: I present … the nursing documentation. Nursing. 2006;36(1):56-62. 3. Maryniak K. Documentation for nurses: legalities of documentation. Western Schools Web site. https:// www.westernschools.com/ce-course/ nursing-ce-course/documentationfor-nurses-legalities-of-documentation-3928.aspx. Accessed July 30, 2016. 4. Legal and ethical implications of documentation. In: Nursing Know-How: Charting Patient Care. Philadelphia, PA: Lippincott, Williams & Wilkins; 2008:67-70. 5. Iyer P. 24 nursing documentation mistakes that could get you sued. Pat Iyer Web site. http://patiyer.com/pdfproducts/24-Nursing-DocumentationMistakes.pdf. Accessed May 9, 2016. 6. Guido GW. Legal and Ethical Issues in Nursing. 6th ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2014. 7. Yokum RF. Documenting for quality patient care. Nursing. 2002;32(8):5863.
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IN THE OR Organizing Your Reporting Data4 Patient’s history: present illness or surgery, medications, significant comorbidities Assessment: • Pain out of proportion to the diagnosis or procedure • Complete set of vital signs • Unusual behavior — irritability, hallucinations, agitation, • Change in level of consciousness sense of impending doom • Changes in perfusion as indicated by skin color, oxygen • Change in a wound or drainage status saturation, and urine output • Relevant diagnostic test results
CLINICAL VIGNETTE Bob Bryan, RN, is working the evening shift at a rehab facility. The patients he is caring for include 70-year-old Mrs. Jorgensen, who had total hip replacement; 45-year-old Mr. Caldwell, who is a paraplegic from a motorcycle accident; and 80-year-old Mrs. Lowe, who has congestive heart failure and has dementia. 1. At 19:15, Mr. Caldwell requests oral pain medication. Which of the following documentation practices regarding administration of pain medication is considered falsification of records? a. C harting an assessment of Mr. Caldwell’s need for pain medication b. Charting that Mr. Caldwell is given medication in advance c. Charting that Mr. Caldwell is given medication immediately after it is given d. C harting Mr. Caldwell’s response to the pain medication
vital signs now are BP 90/62 mmHg, pulse 118 beats per minute, and respirations 24 breaths per minute. The following information is important for Bob to document: a. Changes in vital signs and patient’s complaint of shortness of breath b. Changes in vital signs, patient’s complaint of shortness of breath, the type of snack the patient was having, and an immediate call to the patient’s physician c. Changes in vital signs, patient’s complaint of shortness of breath, and an immediate call to the patient’s physician d. An immediate call to the patient’s physician
2. To protect himself from litigation when caring for Mrs. Lowe, Bob should ensure that his documentation 4. F our years have passed since Mrs. Jorgensen had a includes: pulmonary embolus after her other hip replacement a. All safety precautions surgery. Her family is suing the physician and nurse b. Mrs. Lowe’s activity level for negligent care. Which of the following statements c. Mrs. Lowe’s food intake in Mrs. Jorgensen’s medical record may place Bob at d. The use of only approved abbreviations legal risk? a. “20:40 — Notified Dr. Brown of change in patient’s condition.” 3. A t 20:40, while having a snack, Mrs. Jorgensen b. “20:40 — Patient complaining of shortness of breath.” complains of shortness of breath. Her vital signs at c. “20:40 — Sudden change in patient’s vital signs (note 18:00 were BP 126/83 mmHg, pulse 86 beats per specifics).” minute, and respirations 14 breaths per minute. Her d. “Called MD to report a change in patient’s condition.”
1. Correct Answer: B Charting any medication, treatment, or other intervention in advance of administering it is considered falsification of records. Only the plan of care may be documented in advance.
4. Correct Answer: D This entry does not specify the name of the physician called or the time of the call. This omission will make it impossible for the nurse to prove that he called a specific person at a specific time. 3. Correct Answer: C Charting sudden changes in vital signs, a patient complaint of shortness of breath, and an immediate call to the physician are essential factors to document. The type of snack the patient was having at the time of this incident is not relevant unless the patient has a known allergy to a specific food. OR TODAY | November 2017
2. Correct Answer: A Because of her dementia, Mrs. Lowe is at high risk for a fall or other injuries. Although the nurse should document activity level and food intake, and should always use only approved abbreviations, charting specific safety precautions, such as side rail placement, demonstrates that the nurse is individualizing care for this at-risk patient.
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HOW TO EARN CONTINUING EDUCATION CREDIT CONTINUING EDUCATION CE510G
8. Monarch KM. Documentation, part 1: Principles for self-protection. Preserve the medical record--and defend yourself. Am J Nurs. 2007;107(7):58-60. 9. Pressure sores: court case points out importance of nursing documentation. Legal Eagle Eye Newsletter for the Nursing Profession Web site. http://www.nursinglaw.com/ pressuresore.pdf. Published June 1997. Accessed May 9, 2017. 10. McGrath T. Man sues home health care for medical negligence. USAttorneys.com Website. https://usattorneys. com/medical-malpractice/man-sues-home-health-care-formedical-negligence/. Published February 2015. Accessed June 7, 2017. 11. Patient’s falls: nurses ruled not negligent based on solid nursing documentation. Legal Eagle Eye Newsletter for the Nursing Profession Web site. http://www.nursinglaw. com/documentation2.pdf. Published February 2008. Accessed July 30, 2016. 12. Dehydration: nursing interventions could have saved patient, lawsuit to go forward. Legal Eagle Eye Newsletter for the Nursing Profession Web site. http://www. nursinglaw.com/dehydration5.pdf. Published October 2010. Accessed July 30, 2016. 13. Smith LS. How to chart by exception. Nursing. 2002;32(9):30. 14. Carelock J, Innerarity S. Critical incidents: effective communication and documentation. Crit Care Nurs Q. 2001;23(4):59-66. 15. Benner P, Hooper Kyriakidis P, Stannard D. Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-in-Action Approach. 2nd ed. New York, NY: Springer Publishing Company, LLC; 2011.
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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 8/15/2018 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.
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CORPORATE PROFILE
INNOVATIVE MEDICAL PRODUCTS’ UNIVERSAL STERIBUMP® Combats Healthcare Associated Infections
“WHY BUNDLE, WHEN YOU CAN BUMP?” More than a pithy maxim, the preceding query raises an important question for OR personnel and hospital administrators who are charged with ensuring that any material entering the sterile field during surgery needs to be as free from contaminates as possible in order to prevent surgical site infection. Historically, cloth was the primary material of hospital sheets, towels and gowns used in surgical procedures. But cloth has several major drawbacks. Cloth material requires washing, mending, sterilizing and storing. Cloth also has to be watched for fraying and emitting foreign debris or lint into the sterile field that could contaminate the surgical site. AORN guidelines point out that lint and debris can be carried on air currents throughout the operating room. Such microorganism contaminates can fall on any surface including floors, exposed skin of the
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OR TODAY | November 2017
surgical staff, and monitor screens to which bacteria can adhere. As OR staff move around the operating room, and equipment pieces are repositioned, the now-contaminated debris can be sent airborne again, potentially landing on surgical instruments, drapes, and gloves, or directly onto the open surgical wound itself. If cloth drapes and gowns once presented a potential threat to patient safety, not to mention making extra work for hospital staff, and incurring no small cost for hospital administrators, why are cloth bundles still in use today when positioning patients for surgery? Because the use of cloth bundles is plainly problematic, the question remains: “Why bundle, when you can bump?”
created the Universal SteriBump®, a contoured, polyurethane foam block that is latex-free with a closed cell geometry that significantly reduces foreign particulates. Protected by guaranteed sterile packaging, and ready to use for multiple applications, the SteriBump® is cost effective, guaranteeing product sterility, while providing the patient and the surgical team a physical platform that can securely elevate a patient’s limb in the sterile field when required.
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Advancing beyond cloth bundling, Innovative Medical Products
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BLANKET BUNDLES VS. STERIBUMP® The SteriBump® not only reduces the potential for foreign particulate to become airborne and enter a surgical site, but the IMP solution also offers a consistent size and stable density for a sterile platform that proves to be less costly and less labor-intensive than a handmade bundle. SteriBump’s® contoured cradle shape provides a more secure elevated positioning of the patient’s extremities in the sterile field, and its rectangular design provides a choice of multiple heights and angles for such procedures as extremity trauma, vascular surgery, shoulder abduction, lateral shoulder arthroscopy, carpal tunnel, and incision closure of total hip or total knee surgeries. Using the SteriBump® is easier, faster and safer than bundling towels. Its single-use feature means there’s never a question of sterility, eliminating the possibility of cross contamination. Further, the polyurethane foam SteriBump® WWW.ORTODAY.COM
offers surgeons a more stable, rigid, positioning solution that will not shift or move during surgery as often happens with cloth bundling. As one Central Sterile Services (CSS) administrator noted, “Our hospital purchased the Universal SteriBump® to replace our handmade ‘bundles’ for many of the same reasons that hospitals moved away from re-sterilizing cloth OR table drapes some years ago. The SteriBump® is consistent in size, shape and density unlike handmade ones that potentially fall apart. “There is also a cost savings over bundles which need to be laundered and sterilized after each use. Inventory can be reduced by eliminating the lead-time necessary to make the bundles. Also, we like the SteriBump’s® contoured shape that can capture the patient’s limb and reduce its movement unlike our bundles, providing an excellent sterile platform for multiple surgical procedures.”
The estimated extra costs in time by using a blanket bundle method, rather than the SteriBump®, is about 50 minutes, requiring at least these eight steps: 1. choice of blanket 2. roll blanket to form bundle 3. wrap bundle with disposable wrap for sterilization 4. sterilize bundle 5. unroll bundle after use 6. wash blanket 7. return blanket to supply 8. lint removal Besides extra costs in time, there are also fixed costs to consider when bundling blankets, such as the price of materials including disposable wrap and laundry costs. November 2017 | OR TODAY
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CORPORATE PROFILE
“Why bundle, when you can bump? That is a question perhaps all OR personnel and hospital administrators might consider,” said Earl Cole, Innovative Medical Products vice president. “From our viewpoint, it’s a simple matter of cost and time savings, not to mention making the patient more secure during surgery and with less chance of infection.”
“ From our viewpoint, it’s a simple matter of cost and time savings, not to mention making the patient more secure during surgery and with less chance of infection.”
WHERE DO LINT/ FIBERS COME FROM? One study found that cotton huck towels are the number one producer of lint which has been identified as the most frequent contaminate carrier contributing to post-surgical complications. Lint fiber contaminates can carry microorganisms that are capable of increasing a patient’s infection risk, such as producing adhesions, infections, granulomas, and blood clots.
STERIBUMP’S® ‘COMPANION’ POSITIONER: SUPERBUMP™ A companion positioning solution to IMP’s SteriBump® is the SuperBump™, a guaranteed, sterile, weighted bump, employed when simplicity is all a surgical team needs for a knee procedure. Positioned on top of the OR table’s drapes at any location for knee flexion, the contoured, latex-free, foam-based SuperBump™ cradles the leg during closure. The SuperBump™ is packaged sterile and accepts two, fivepound stainless steel weights to anchor the IMP positioner in place during the surgical procedure. The steel weights also come with a sterilization case for autoclaving and storage. CONCLUSION Surgical site infection is one of the most common hospital-acquired complications in surgical patients leading to longer hospital stays, which, in turn, results in higher inpatient costs. Implementing solutions that help prevent infection improves patient care while lowering the duration and cost of hospital stays in patients at risk. “The bottom line,” notes IMP’s Earl Cole, “is that the SteriBump®, and the SuperBump™, are positioning solutions that can help reduce the occurrence of infection, save time and money, and increase patient care. Seems like that’s a good answer to the question, “Why bundle, when you can bump?” For more information about the SteriBump® and SuperBump™, visit www.impmedical.com.
48 OR TODAY | November 2017
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STOP
BULLYIN AND PROMOTE UNITY
50 OR TODAY | November 2017
WWW.ORTODAY.COM
When we think of bullies, we usually think of kids
NG
BY DON SADLER
picking on and being mean to each other, especially kids who are different in some way. Unfortunately, bullying occurs among adults more often than we might realize – including in the operating room.
Bullying has long been a problem in the OR that is too often swept under the rug. In fact, The Joint Commission has identified bullying as a Sentinel Event that “fosters medical errors and contributes to poor patient satisfaction and preventable adverse outcomes.” A SIGNIFICANT, PERSISTENT ISSUE A study conducted by the Association of periOperative Registered Nurses (AORN) reveals just how prevalent OR bullying is. Approximately 6 out of 10 (59 percent) perioperative nurses and surgical technicians who responded said they had witnessed coworker bullying on a weekly basis In addition, more than three out of 10 (34 percent) respondents said they had witnessed at least two bullying acts per week. “Statistics like this indicate to me that bullying is a significant issue in operating rooms all across the country,” says Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, the CEO and Executive Director of AORN. WWW.ORTODAY.COM
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“These statistics tell us that bullying or intimidating behaviors continue as a persistent issue in health care, and in the operating room environment in particular,” adds Coleen A. Smith, RN, MBA, CPHQ, CPPS, Certified RPI Black Belt, Director, High Reliability Initiatives, Joint Commission Center for Transforming Healthcare. Groah defines bullying as “threatening behavior based on intimidation that stems from the bully’s issue with personal power over a colleague. Bullying interferes with effective health care communication and thus threatens a culture of patient safety.” Examples of common OR bullying tactics cited by Groah are withholding information, sabotage, scapegoating and backstabbing. Smith adds intimidation, harassment, victimization, aggression, emotional abuse and psychological harassment to the list. Incivility is another source of negative and dangerous behavior in the OR. “This includes rude or disruptive behaviors such as eye-rolling and making disparaging remarks when a team member insists on following
COLEEN A. SMITH, RN, MBA, CPHQ, CPPS 52
OR TODAY | November 2017
protocol, such as the surgical time out,” says Groah. “In this situation one practitioner is not respectful of the other person’s contribution to the team and demonstrates this either verbally or non-verbally during an encounter,” adds Groah. SAFETY PUT AT RISK According to Smith, any time a health care worker in any setting is intimidated or bullied, this puts the safety of the health care worker and patients at risk. She lumps disrespectful behaviors in with bullying. These are described by the Institute for Safe Medication Practices as ranging from “overt acts of abuse and bad behavior to insidious actions so embedded in our culture that they seem normal, such as gossip.” Smith describes a “punitive and disrespectful culture” as one where “there is little trust, teamwork is difficult, reports are inhibited, and the communication and collaboration that are essential for excellent patient care are compromised.” “Organizations with such cultures are not likely to learn from their mistakes, which makes harm more likely,” adds Smith. DOWNWARD VS. LATERAL BULLYING Bullying in the OR is usually thought of as surgeons being threatening, intimidating or verbally abusive toward other perioperative team members. This is known as downward bullying. However, lateral bullying – or bullying between colleagues – is just as common. Younger OR nurses, in particular, are susceptible to being bullied by older and more experienced colleagues, according to a study conducted by the Robert Wood Johnson Foundation. So are nurses working the day shift and those
working in an understaffed unit. Groah believes that downward bulling can be more damaging than lateral bullying to perioperative team members’ self-esteem and may have a longer-term impact on their career. “Supervisors should have a positive, nurturing attitude toward team members, not a negative, ‘out to get you’ attitude,” says Groah. “Most OR personnel see their managers as role models and want to please them by performing well. They need positive recognition and feedback to reach professional fulfillment.” Cindy Mask, CST, FAST, AA, BAAS, Program Director of Surgical Technology at Tarrant County College in Ft. Worth, Texas, stresses the importance of teamwork and collaboration in the OR. “It’s critical that the surgeon, nurses, anesthetists, surgical technologist and all other OR team members work together collaboratively,” says Mask.
More than three out of ten (34 percent) respondents said they had witnessed at least two bullying acts per week.
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She cites a recent study that found there were teamwork issues underlying up to 75 percent of completed malpractice claims. In another study, less than half of the staff in a majority of the hospitals surveyed said that they experienced good teamwork. Not only do bullying and incivility in the OR have the potential to threaten patient safety, but they can also be costly to health care organizations. Mask points to a 2011 court decision (Tuli v. Brigham &
unacceptable behavior,” she says. “In a just culture, individual accountability is established and appropriate actions are taken when disruptive behavior is reported,” Groah adds. “Leaders have a responsibility to create an open and supportive environment where team members’ concerns and questions are responded to without retaliation.” If any kind of bullying or incivility does occur, it should be investigated as soon as possible after the incident and the findings
“I STRONGLY BELIEVE THAT EVERY PATIENT DESERVES A SURGICAL EXPERIENCE IN WHICH HE OR SHE IS THE SOLE FOCUS OF THE ENTIRE SURGICAL TEAM.” - CINDY MASK
Women’s Hospital) in which a jury ordered a hospital to pay a total of $1.6 million in damages for failing to reign in a disruptive physician. “This underscores the need for hospitals to promptly address and respond to complaints of disruptive behavior,” says Mask. “This includes discriminatory or retaliatory conduct.” Shifting the OR environment away from one of bullying toward one of cooperation and teamwork starts with creating a code of conduct with “a zero tolerance toward bullying and other toxic behaviors,” says Groah. “This should be communicated during the orientation of all new OR personnel hires.” Groah also stresses the importance of implementing what she calls a “just culture” in the OR. “This creates an environment of trust in which all perioperative team members are acutely aware of the distinction between acceptable and WWW.ORTODAY.COM
reported to HR or the appropriate person or department. “And prompt feedback needs to be provided to all the individuals who were involved in the incident, as well as the final results of the investigation,” says Groah. 5 CS OF ELIMINATING BULLYING Mask has identified what she calls the “5 Cs” of eliminating bullying and promoting teamwork in the OR: 1. Improve Communication 2. Focus on Culture 3. Stress Collaboration 4. Build Camaraderie 5. Practice Conflict resolution “I strongly believe that every patient deserves a surgical experience in which he or she is the sole focus of the entire surgical team,” says Mask. “Denying any patient of this is deplorable, in my opinion.” Smith points to The Joint Commission’s recently released Sentinel Event Alert 57 that stresses
CINDY MASK, CST, FAST, AA, BAAS
the essential role of leadership in developing a safety culture in health care organizations. “This Alert stresses the fact that to advance trust within the organization, health care leaders must adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors, including behaviors in the OR,” says Smith. “Physician and nursing leaders should both model appropriate behaviors,” adds Smith. “In addition, there should also be a structure in place to allow for non-punitive reporting of issues related to bullying and an effective governance structure to respond to such instances.” Visit http://bit.ly/2mS9duZ to download an infographic created by The Joint Commission discussing the 11 tenets of a safety culture in health care organizations. A TOUGH QUESTION So is bullying a problem in your healthcare organization? Mask says you should ask yourself whether or not you would have surgery in your own hospital. “If the answer is ‘no,’ then you’ve got some work to do,” she says.
November 2017 | OR TODAY
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ElizabethSparaco BY MATT SKOUFALOS
ThefirsttimeElizabethSparacocompletednursingschoolwas in1981.Itwouldbeanother30yearsandtwocareersbeforeshe returned.AftergraduatingfromCamdenCountyCollegewithher nursingcertificate,Sparacobeganworkingincriticalcare,eventuallyrisingtopositionsofadministrativesupervisionbeforeshe lefttheprofessionforconsultingopportunitiesinthemid-2000s. “When I first started, nurses were not autonomous,” Sparaco said. “They weren’t really a part of the decision-making, and there was no such thing as shared decision-making with patients. I remember when EHR [electronic health records] first came in, in the 1980s, and we were using pneumatic tubes to send orders to the pharmacy.” Sparaco eventually decided to return to nursing because she wanted to get back into active patient care. She started by going back to school. In 2012, she completed an EHR certificate program to familiarize herself with technological advancements in the field, finished a second certification as a medical health coach and spent another two years completing a bachelor’s degree program at Rowan University to support a move into the field of population health. 54
OR TODAY | November 2017
In August 2016, Sparaco became manager of population health for the Kennedy Health System in Cherry Hill, New Jersey, heading up a program with 10 RNs, two LPNs, a health coach, and a social worker to manage an active patient population of 80,000. She had begun that work only a few years earlier when she was chosen to implement a special, chronic care management initiative for patients with two or more illnesses. After three decades in the field, Sparaco felt like she was where she’d been meant to be all along. “I feel like I’m hitting my stride now, where it’s all starting to come together,” she said. “The senior administration at Kennedy, they really do get it. It’s helping move the whole transition of care team, and encouraging communication and shared management of the patient. We have an established medical neighborhood
and lots of care contacts to come in with our patients.” In the years since she entered the field, Sparaco said she’s seen health care institutions make the necessary evolution to empower nurses to be more autonomous. The philosophy of partnering nurses with physicians and nurse practitioners for the care and management of their patients wasn’t part of her education the first time around, but since its arrival, the field has been amidst a necessary transformation. “We always said as nurses we wanted this kind of care coordination for the patient, and here we are,” Sparaco said. “When you do get that and you can establish workflows so WWW.ORTODAY.COM
“I tell my team, ‘You are the leaders out there. Take initiative, make sure you’re proactively approaching the staff to see if they need any clinical assistance, any education. Never stop believing or acting as a leader,’ ” she said. As the demands of the profession escalate and become more complicated, Sparaco believes those nurses who seize upon their profession as a career and not just an occupation will be the most successful in the field. With the tremendous variety of specialties and job openings available, nurses who empower themselves to be self-sufficient practitioners will have the greatest opportunities available to them. “I would like to see nurses focus on their passions and what type of nursing they would focus on in order to develop that [career],” Sparaco said. “We have so much to offer in so many different ways that I think we can benefit society and our patients by being more autonomous.”
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them self-manage their conditions and live their best lives. “When I see that happen, it is just the best,” Sparaco said. “I went into [medicine] for that exact reason, to be able to do that for a patient, and I think it’s happening now. Three years ago, most people didn’t know what a medical neighborhood was, and now everybody gets the idea of how to manage a patient. It’s real exciting to see the teams working together now and getting it.” Sparaco is a staunch advocate of continuing education for nurses. She tells her young charges to pursue the highest levels of learning that they can; to not stop until they have earned at least a master’s degree because “it’s never going to be any easier.” As nurses are called upon to be more independent in their practices, and are no less in demand to care for the patients they serve, their input will only be more valuable. That’s why Sparaco emphasizes leadership training for her staff and works to help them feel empowered in their practice.
di
we’re working together to manage the patients, it is a whole different world. We can capture our patients before discharge to make sure they get what they need. That’s a really huge leap from where I started.” In the early days of her career, nurses relied on episodic care, Sparaco said; patients weren’t tracked, their progress or deterioration charted against baseline measurements. In the intervening decades, systems for the delivery of care have transitioned into a longitudinal approach that not only feels more like what she set out to do as a nurse from the beginning, but is “what’s keeping me in the game at my age,” Sparaco said. “I know more nurses than not who have said over the decades, ‘If only this doctor knew what that doctor was doing, they wouldn’t be repeating tests; running [patients] to different specialists,’” she said. “You pretty much had to have somebody in the family who knew about medicine or the redundancy would be crazy.” Sparaco also shares this perspective with the nursing students she speaks with, reinforcing for them not only how important they are to their patients, but how their ability to practice health care independently and to advocate for their role in patient care is critical to the health outcomes they offer. As health care has evolved to identify and treat patients with complicated comorbidities and psycho-social needs, every level of care that a nurse can deliver – medication, education, support, health coaching – is necessary to help
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55
OUT OF THE OR FITNESS
BY ALEXA CORTESE
6 WAYS
TO FIND A FITNESS BUDDY
L
ike many other activities, exercising is generally more fun when done with a friend. And a study conducted at the University of Pennsylvania School of Medicine suggests that exercising with a partner improves weightloss results, too. Whether you’re trying to shed a few pounds or simply want to maintain a healthy lifestyle, here are some great strategies to find a fitness friend.
4
ASK YOUR TRAINER/COACH
Talk to a professional at your gym to see if she knows of anyone who is interested in finding a workout partner. The trainer may know someone who shares your skills and interests – and it never hurts to connect through a mutual acquaintance.
5
REACH OUT TO FRIENDS
1
GO TO MEETUP.COM
It’s tough not to be inspired by the fun things people are signing up for on this site, the world’s largest network for special-interest groups. You can find anything from a local hiking group to meet-ups for exercising with your pets – so finding someone who wants to commit to meeting up for a trail run on a Tuesday evening shouldn’t be too much of a stretch.
2
LOOK ON ZOGSPORTS.COM
With a focus on young professionals, this organization provides a great way to sign up for intramural teams, classes, clinics and social events. Some of the proceeds go to charity,
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OR TODAY | November 2017
making this a worthwhile way to meet an exercise buddy.
3
FIND LIVINGSOCIAL/ GROUPON DEALS
Thanks to the deeply discounted prices for fitness-related classes, it’s easier than ever to sign up for anything from yoga classes to rockclimbing lessons. The adrenaline rush from trying something new (like trapeze or stand-up paddleboarding) can create a bond between people, so strike up a conversation with someone else in your class. Since you’re both out there trying new activities, you may discover a shared interest in running, walking or the sport that interests you most.
This may seem obvious, but working out is actually a great way to spend time with friends who you seem to lose touch with or go months without seeing. Instead of letting your busy lives get in the way of bonding time, you can take a monthly or weekly class together to stay fit and catch up on each other’s lives.
6
ASK AROUND AT WORK
Have a co-worker who seems like she’s just as interested in healthy living as you are? A colleague is a great workout buddy since you see each other every day and have similar schedules. That may provide just the motivation you need to get in the habit of a lunchtime walk or run together.
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OUT OF THE OR HEALTH
BY MARILYNN PRESTON
MAD IS BAD
SO MANAGE YOUR ANGER — OR ELSE!
W
ho isn’t angry about something these days? Take my friend Sam: a sweet husband and docile dad, but put him in heavy traffic and he starts foaming at the ears. He’s angry at stopped cars, passive drivers, even angry at himself for choosing the slowest lane.
Lisa has a hair trigger, too. She can go from friendly to furious in a single breath. (If only she would take five in a row and exhale to a count of four.) Her newest pet peeve? Unconscious imbeciles who shout intimate details
the queen mother of angermaking, otherwise known as the 2016 election. I’m not taking the Democratic side. I’m not talking the Republican side. I’m taking the side of peaceful co-existence,
“Holding on to anger is like grasping a hot coal with the intent of throwing it at someone else. You are the one who gets burned.” -BUDDAH of their lives into their cellphones with no regard whatsoever for the people around them. “I can hear you!” she bellows, flames emerging from both nostrils, looking very “Game of Thrones.” And then, of course, we have 58
OR TODAY | November 2017
a united state in America where harmony and understanding prevail and we’re listening to each other and solving problems for each other, while moving steadily toward healthier, happier lives for all of us.
The wheels are completely off that bus. So don’t get angry when I remind you that if you want to live a healthier, happier lifestyle, it’s not enough to eat well, exercise often and use a standing desk. You’ve also got to do something to manage your hostility and let go of resentment, bitterness and other toxic emotions. “Holding on to anger is like grasping a hot coal with the intent of throwing it at someone else,” the Buddha taught. “You are the one who gets burned.” There is plenty of research to show that feeling anger – for too often or too long – puts an enormous strain on your health. It boosts your blood pressure and tenses your muscles, setting you up for pain, pills and doctors’ bills. Anger also triggers a dump of chemicals into your body – including epinephrine and norepinephrine – that can, over time, clog up your blood vessels and damage your heart. There are other nasty effects, WWW.ORTODAY.COM
HEALTH
too, but rather than dwell on the problem, let’s look instead at a few positive strategies:
WHIP OUT THE LAVENDER
At the first sign of upset, start conscious breathing. It’s one thing to express frustration. Anger is something else. It’s like throwing up: You know when it’s happening. To defuse it on the spot, count to 10 or breathe deeply until anger gives way and serenity moves in.
This belongs in the category of minor miracles. Next time you’re feeling your cork about to pop, whip out a small bottle of lavender oil and take a few whiffs. Inhale slowly. Exhale deeply. Essential oils are penicillin for the brain. They work quickly, and the brain responds in kind. Lavender is a popular essential oil known to relax and calm you, and the only nasty side effect is getting oil on your pants if you spill it.
STEP ASIDE
MEDITATE
BREATHE YOURSELF DOWN
If you feel someone else’s anger coming your way, don’t meet it head on. Rise above it. Imagine yourself just stepping aside – an elegant move you can master in an aikido class – and let their threatening and thoughtless behavior blow by. Remain calm and in control. It’s a sign of strength, not weakness.
You can train your brain to be calm and clear by developing a meditation practice. A few minutes a day on the pillow or in a chair – eyes closed, relaxed, focusing on your breath or a mantra – is a blissful way to transform anger into gratitude. How cool is that? STOP AND (RE-) THINK
Neuroscientists tell us the mind
attaches to the negative. This helped us survive in caveman times, when every animal was a threat. These days? The fight-or-flight response disturbs our peace. So notice your quick negative reactions to events or people, and when you observe yourself getting angry, stop and switch course. Is anything really wrong? To return to a calm state, do something proactive instead of reactive. Snap your fingers or pull on your ear.
– Marilynn Preston is the author of Energy Express, America’s longestrunning 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 wellbeing, visit www.MarilynnPreston.com.
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November 2017 | OR TODAY
59
OUT OF THE OR NUTRITION
BY LORI ZAANTESON
HOW TO SAY NO TO FOOD PUSHERS
W
hen you’re working hard to make healthy lifestyle changes, sometimes the people around you are a huge source of support and motivation. Sometimes, not so much. Maybe you have an aunt who brings you her famous banana bread when she visits – or a spouse who gets annoyed when you’d rather walk than watch TV after dinner. Food pushers probably aren’t deliberately sabotaging you, so take a minute to help them understand your needs. Here are some ideas about how to talk about trying to make healthy lifestyle choices. MAKE PEOPLE AWARE OF WHAT THEY’RE DOING
Try bringing up the subject of foodpushing in a nonconfrontational way. Many times, their behavior isn’t intentional; for example, it simply may not have occurred to your aunt that her banana bread isn’t appropriate for someone who’s watching what he or she eats. Bringing the issue out into the open may be all that’s needed. Consider the reasons behind 60 OR TODAY | November 2017
their actions. A person who doesn’t seem supportive of your new lifestyle may be missing an activity you’re no longer able to share with them – say, the daily doughnut break. Talking about it can help, especially if you can come up with alternatives that accommodate you both – for instance, meeting your doughnutbreak buddy for a daily walk instead of pastries.
you succeeding at your goals makes them feel threatened or inadequate. If you’re unable to resolve the problem, don’t let it hold you back. Focus instead on seeking the support you need from other sources. BE KIND BUT FIRM
When people offer a food and you reject it, they may feel like you’re rejecting them, too, so you need to
DON’T LET THEM HOLD YOU BACK
Some people in your life may not truly support your efforts. Perhaps the thought of
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be sensitive to that. If you’re offered something you’d rather not eat, choose phrases that acknowledge the person’s feelings, but still make your point: “That looks amazing, and I wish I had room, but I’m really enjoying the [insert other food here].” If you’re offered a second helping you don’t need, keeping your reply in the past tense gives your words a sense of finality: “It sure was delicious, but I’ve had enough.” PRACTICE, PRACTICE, PRACTICE
If you struggle with sticking to your healthy habits in certain situations, take some time ahead of the event to imagine what it will be like, being as specific as possible. Who will be there? What will be served? How will you act and what will you say? Rehearse as much as you need to, until you feel you can head into the festivities with confidence.PROOF APPROVED CLIENT SIGN–OFF:
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OUT OF THE OR RECIPE
62
OR TODAY | November 2017
BY CAROLYN MALCOUN
WWW.ORTODAY.COM
RECIPE
SLOPPY JOES MADE HEALTHY
T
his vegetarian sloppy joe recipe uses pinto beans and a heap of veggies tossed in a sweet, tangy sauce for the filling of a tad messy kidfriendly sandwich you can make in your slow cooker.
VEGETARIAN PINTO BEAN
SLOPPY JOES
Serves: 10 Serving Size: About 2/3 cup and 1 bun
DIRECTIONS
Heat oil in a large skillet over medium-high heat. Add carrots and onion; cook, stirring occasionally, until starting to brown, about 8 minutes. Stir in garlic and chili powder; cook, stirring, until fragrant, about 15 seconds. Remove from heat; stir in vinegar and scrape up any browned bits. Coat a 6-quart slow cooker with cooking spray. Drain and rinse the soaked beans; transfer to the slow cooker. Stir in bell pepper,
Active Time: 30 minutes
tomato sauce, water, soy sauce (or tamari) and tomato paste to combine. Spread the carrot-onion mixture over the bean mixture, but don’t stir the two together. (The layer on top helps keep the beans submerged during cooking so they don’t dry out.) Cover and cook on high for 5 hours or low for 9 hours. Stir in cabbage, zucchini, corn, honey mustard, brown sugar and salt; cook on high for another 30 minutes. Serve the mixture on buns.
RECIPE NOTES:
Before using beans in a slow-cooker recipe, soak them to ensure even cooking. Start by sorting beans to remove any pebbles; rinse well with cold water. To soak overnight, place beans in a large bowl, cover with 3 inches of cold water and soak at room temperature for 8 to 24 hours.
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To “quick soak,” place beans in a large saucepan with enough cold water to cover them by 2 inches. Bring to a boil. Boil for 2 minutes. Remove from the heat, cover and let stand for 1 hour. To make ahead, cover and refrigerate for up to two days; reheat before serving.
Total Time: 5 1/2 hours to 9 1/2 hours FOR THE SAUCE: 2 tablespoons extra-virgin olive oil 2 medium carrots, sliced 1 large white onion, sliced 4 cloves garlic, minced 3 tablespoons chili powder 2 tablespoons balsamic vinegar 1 cup dry pinto beans, soaked 1 large red bell pepper, diced 1 (8-ounce) can no-salt-added tomato sauce 1/2 cup water 2 tablespoons reduced-sodium soy sauce or tamari 2 tablespoons tomato paste 4 cups very thinly sliced green cabbage 1 medium zucchini, chopped 1 cup corn, fresh or frozen (thawed) 3 tablespoons honey mustard 1 tablespoon brown sugar 1 teaspoon salt 10 whole-wheat hamburger buns
November 2017 | OR TODAY
63
OUT OF THE OR PINBOARD
PINBOARD
The News and Photos That Caught Our Eye This Month
OR TODAY
CONTESTS • OCTOBER •
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THE WINNER GETS A $50 SUBWAY GIFT CARD
YOU MIGHT BE A FOODIE IF... Foodies are also more According to the International Food Information Council (IFIC) Foundation’s 2017 Food and Health Survey, a foodie is someone who sacrifices convenience and cost in search of a quality product, particularly one that is tasty, healthy and made in a way that aligns with their personal beliefs. Foodies also have a different definition of healthy food compared to other Americans. While the other five profile groupings consider a healthy food to be “part of an important food group,” foodies are the only group to include “minimally processed” in their top three attributes of a healthy food. Foodies also chose “free from artificial ingredients, additives” and “high in healthy components or nutrients,” rounding out their definition of healthy. 64
confident in their nutrition know-how. While only 44 percent of the general population could name a food or nutrient associated with their most desired health benefit, 60 percent of foodies were able to do so. In addition, when confronted with conflicting nutrition information, this group was among the least likely to doubt their food decisions. Other groups prioritize the cost and convenience of food while foodies are more likely to sacrifice these purchase drivers for quality. They are also not as concerned with sustainability or packaging. However, for foodies, taste still reigns supreme when deciding to purchase a food or beverage. According to the survey, foodies are predominately female (63% female vs. 37% male), have
OR TODAY | November 2017
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higher incomes (52% make more than $75,000 a year) and a median age of 58. They are also less likely to have kids under 18. This might partially explain why foodies aren’t as concerned about convenience or the cost of food. “As in previous years, the Food and Health Survey has shown us what drives consumers in their food purchasing decisions, but this is the first year we took a look at how foodies distinguish themselves from consumers generally,” said Alexandra Lewin-Zwerdling, Ph.D., vice president of research and partnerships at the IFIC Foundation. “Our hope is that by better understanding the attitudes, perceptions, and habits behind consumer behavior, we can work with partners to enhance and develop effective nutrition education strategies.”
Win Lunc h!
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RACHEL MALINOWSKI PRESIDENT, WESTERN WISCONSIN CHAPTER OF IAHCSMM
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A SHORT “THE BEST REMEDY FOR .” TEMPER IS A LONG WALK – JOSEPH JOUBERT
WIN A YEAR OF MAPLE PRODUCTS of Destination America Could you use more maple in your life? Vermont’s The Maple Guild invites anyone with a taste for maple-y goodness to bust out their aprons and cocktail shakers to enter the inaugural Maple It Recipe Contest. All entrants will receive a buy one, get one offer of any products from The Maple Guild. The Maple Guild is looking for creative recipe submissions showing how you can take classic and new dishes to a maplier level with the addition of The Maple Guild’s syrups, beverages, and award-winning maple vinegar and maple cream. Entrants will be funneled into three categories – Barbeque, Baked Goods, and Beverages – all judged by partners with expertise in the recipe category. Myron Mixon, the winningest man in barbeque, holding more than 200 competitive championships, and the star WWW.ORTODAY.COM
Network’s BBQ Pitmasters will serve as the BBQ category’s partner and judge. His restaurant, Myron Mixon’s Pitmaster Barbeque, in Alexandria, VA uses maple syrup and sugar in recipes and cocktails. Jos. A. Magnus & Co., the national award-winning distiller from Washington, D.C., will judge all beverage entries. “The days of people only using maple syrup for breakfast are over. From maple waters lining the shelves at grocery stores, maple-based sauces on barbeque menus, and syrup used for extra oomph in coffee, baking, and cocktails, we want consumers to realize how versatile and healthy The Maple Guild’s maple products are as natural sweeteners and flavor enhancers,” said John Campbell, VP of Marketing and Sales for The Maple Guild. Designed to showcase the versatility of
maple, the contest will award three total prizes, with one winning recipe in each category. Each category winner will receive a year’s worth of maple products, sent in quarterly shipments, as well as a gift basket from the category partner. Judges will select the five top dishes in each category, and fans will be responsible for selecting the winning recipe. Submitted recipes can be an existing menu item or social media post, or a new dish created specifically for this contest. Entries will be accepted through December 5, 2017. Anyone interested in getting their maple on can visit mapleguild.com/mapleit to enter or get more information about the contest. November 2017 | OR TODAY
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INDEX ALPHABETICAL AAAHC………………………………………………………… 34
Cygnus Medical………………………………………… IBC
Palmero Health Care………………………………… 25
AIV, Inc.……………………………………………………………17
Flagship Surgical, LLC……………………………… 35
Paragon Services………………………………………… 57
AORN…………………………………………………………… 10
Healthmark Industries Company, Inc.…… 45
Pure Processing……………………………………………… 5
ASCA…………………………………………………………… 59
Innovative Medical Products……… 46-49, BC
Ruhof Corporation…………………………………… 2, 3
Belimed………………………………………………………… 25
Jet Medical Electronics, Inc. …………………… 61
TBJ Incorporated………………………………………… 44
C Change Surgical……………………………………… 15
Key Surgical…………………………………………………… 9
TIDI C-Armor................................................ 16, 17
Capital Medical Resources………………………… 35
MD Technologies, Inc.………………………………… 61
USOC Medical………………………………………………… 4
Cincinnati Sub-Zero…………………………………… 26
Pacific Medical……………………………………………… 6
INDEX CATEGORICAL ANESTHESIA Paragon Services………………………………………… 57 ASSOCIATION AAAHC………………………………………………………… 34 AORN…………………………………………………………… 10 ASCA…………………………………………………………… 59 CARDIAC PRODUCTS C Change Surgical……………………………………… 15 Jet Medical Electronics, Inc. …………………… 61 CARTS/CABINETS Cincinnati Sub-Zero…………………………………… 26 Cygnus Medical………………………………………… IBC Flagship Surgical, LLC……………………………… 35 Healthmark Industries Company, Inc.…… 45 TBJ Incorporated………………………………………… 44 DISINFECTANTS Cygnus Medical………………………………………… IBC Palmero Health Care………………………………… 25 Ruhof Corporation…………………………………… 2, 3 ENDOSCOPY Capital Medical Resources………………………… 35 Cygnus Medical………………………………………… IBC Healthmark Industries Company, Inc.…… 45 Ruhof Corporation…………………………………… 2, 3 ERGONOMIC SOLUTIONS Pure Processing……………………………………………… 5 FLUID MANAGEMENT SOLUTION Flagship Surgical, LLC……………………………… 35 GENERAL AIV, Inc.……………………………………………………………17 Capital Medical Resources………………………… 35 INFECTION CONTROL Belimed………………………………………………………… 25 Cygnus Medical………………………………………… IBC Healthmark Industries Company, Inc.…… 45 Palmero Health Care………………………………… 25
66
OR TODAY | November 2017
Pure Processing……………………………………………… 5 Ruhof Corporation…………………………………… 2, 3 TBJ Incorporated………………………………………… 44 TIDI C-Armor................................................ 16, 17 INSTRUMENT STORAGE/TRANSPORT Belimed………………………………………………………… 25 Cygnus Medical………………………………………… IBC Key Surgical…………………………………………………… 9 INVENTORY CONTROL Key Surgical…………………………………………………… 9 MONITORS Pacific Medical……………………………………………… 6 USOC Medical………………………………………………… 4 OR TABLES/BOOMS/ACCESSORIES Innovative Medical Products……… 46-49, BC OTHER AIV, Inc.……………………………………………………………17 PATIENT MONITORING AIV, Inc.……………………………………………………………17 Jet Medical Electronics, Inc. …………………… 61 Pacific Medical……………………………………………… 6 USOC Medical………………………………………………… 4 POSITIONING PRODUCTS Cygnus Medical………………………………………… IBC Innovative Medical Products……… 46-49, BC REPAIR SERVICES Capital Medical Resources………………………… 35 Cygnus Medical………………………………………… IBC Jet Medical Electronics, Inc. …………………… 61 Pacific Medical……………………………………………… 6 REPROCESSING STATIONS Pure Processing……………………………………………… 5 TBJ Incorporated………………………………………… 44 SAFETY Flagship Surgical, LLC……………………………… 35
Healthmark Industries Company, Inc.…… 45 Key Surgical…………………………………………………… 9 TIDI C-Armor................................................ 16, 17 SINKS Pure Processing……………………………………………… 5 TBJ Incorporated………………………………………… 44 STERILIZATION Belimed………………………………………………………… 25 Cygnus Medical………………………………………… IBC Healthmark Industries Company, Inc.…… 45 TBJ Incorporated………………………………………… 44 SURGICAL TIDI C-Armor................................................ 16, 17 SURGICAL INSTRUMENT/ACCESSORIES C Change Surgical……………………………………… 15 Cygnus Medical………………………………………… IBC Healthmark Industries Company, Inc.…… 45 Key Surgical…………………………………………………… 9 SURGICAL MAT SOLUTIONS Flagship Surgical, LLC……………………………… 35 TELEMETRY AIV Inc.……………………………………………………………17 Pacific Medical……………………………………………… 6 USOC Medical………………………………………………… 4 TEMPERATURE MANAGEMENT C Change Surgical……………………………………… 15 Cincinnati Sub-Zero…………………………………… 26 WARMERS Belimed………………………………………………………… 25 Cincinnati Sub-Zero…………………………………… 26 WASTE MANAGEMENT Flagship Surgical, LLC……………………………… 35 MD Technologies, Inc.………………………………… 61 TBJ Incorporated………………………………………… 44
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The De Mayo V2E Knee Positioner gives you more options for unobstructed access – extension arm positions knee off the operating table. TM
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Surgeon can stand between patient’s legs for greater access approaching the medial compartment Straight-on knee access provides line of sight to surgical site – no need to lean over OR table More precise control of lateral movement and improved boot-holding capabilities Removable Carriage is easier to clean and maintain Lighter Base Plate and handle options improve ease of use New Side Rail Clamp with a positive lock Learn more about the unique features of the De Mayo V 2 ETM Knee Positioner at www.impmedical.com or call 800-467-4944 for more information or to speak with a representative.
The operative word in patient positioning. www.impmedical.com
De Mayo V2ETM Knee Positioner is a trademark of Innovative Medical Products, Inc. U.S. Patent No. 8,132,278 V2ETM Clamp is a trademark of Innovative Medical Products, Inc. U.S. Patent No. 7,003,827
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