OR Today - December 2017

CE ARTICLE PATIENT SAFETY PAGE 30

SPOTLIGHT ON

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TAKE GOOD CARE NURSES • SURGICAL TECHS • NURSE MANAGERS

NUTRITION

WHOLE GRAINS PAGE 54

DECEMBER 2017

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CONTENTS

features

OR TODAY | December 2017

IMPROVING EFFICIENCY

and Performance

40

IMPROVING EFFICIENCY AND PERFORMANCE Insiders share tips for improving operating room efficiency and performance which include updating antiquated processes, planning in advance for surgical procedures, nudging surgeons to perform better and more.

46

SPOTLIGHT ON: SUSAN BORAL After undergoing open-heart surgery as a teenager, Susan Boral, RN, BSN, thought she might someday enter the health care field. Today, she plays a vital role in infection control and population health at Thomas Jefferson University Hospital.

OR Today (Vol. 17, Issue #10) December 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. Š 2017

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December 2017 | OR TODAY

7

CONTENTS

departments

PUBLISHER

John M. Krieg | john@mdpublishing.com

VICE PRESIDENT

Kristin Leavoy | kristin@mdpublishing.com

12

26

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 10 News & Notes 18 AAAHC Update

IN THE OR

54

Kim Callahan

DIGITAL SERVICES Travis Saylor Cindy Galindo Jena Mattison Kathryn Keur

CIRCULATION Lisa Cover Melissa Brand

20 Suite Talk 23 Market Analysis 24 Product Focus 30 CE Article

OUT OF THE OR 48 Fitness 50 Health 54 Nutrition 56 Recipe 60 Pinboard 62 Index

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OR TODAY | December 2017

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

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INDUSTRY INSIGHTS NEWS & NOTES

STAFF REPORT

Belimed Launches Multi-enzyme Detergent Belimed Inc., part of the Belimed Group, has expanded its portfolio of multi-enzyme detergents with the addition of the new Belimed Protect Concentrate PLUS. With the addition of Concentrate PLUS, Belimed continues its commitment to sterile processing environments.

This multi-enzyme detergent was designed and developed by Belimed to optimize the cleaning outcomes delivered by Belimed’s washers and disinfectors.

“Adding the Concentrate PLUS to our cleaning solutions portfolio provides an additional choice for customers to improve CSSD efficiency and lower operational costs,” Belimed’s Susan Harley said.

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,” said Harley. •

SpecialtyCare Adds OR Management and Analytics Solution SpecialtyCare, a provider of outsourced clinical services for operating rooms, has announced the launch of SpecialtyCare OptimizeOR, a user-friendly decision support and analytics system designed to help hospitals improve efficiency in perioperative performance.

OptimizeOR is a data-driven Software as a Service (SaaS) application that enables perioperative leaders to optimize their staff and OR utilization as well as standardize supplies and implant use across surgeons. OptimizeOR has an intuitive interface developed with OR leaders’ needs in mind, helping them increase efficiency in the OR and buttress surgeon productivity and satisfaction. Users have access to key performance measures and can easily manipulate powerful analytics to produce presentation-ready materials specifically designed to drive and represent financial and clinical improvement.

“High-performing operating rooms are essential for hospital success in today’s value-based health care environment,” SpecialtyCare CEO Sam Weinstein said.

“To continue to improve outcomes and lower readmission rates, OR leaders must have access to data that can uncover opportunities to maximize efficiency. This 10

OR TODAY | December 2017

product is a natural extension of SpecialtyCare’s commitment to equip our customers with the resources required to provide the highest quality of patient care at the most responsible cost.”

OptimizeOR is powered by Syus, the industry-standard perioperative analytics tool, and by AORN Syntegrity. SpecialtyCare selected Syus after reviewing several other products and witnessing the results firsthand.

“We are delighted to have been selected by SpecialtyCare to power OptimizeOR,” said Kevin O’Hara, CEO of Syus. “SpecialtyCare is a leader in bringing efficiency and improved outcomes to the OR and we are proud to be able to further those efforts.”

OptimizeOR has access to the nearly 4 million surgical cases in the Syus database. Using that data alongside SCOPE, the SpecialtyCare Operative Procedural Registry, the largest allied health database of its kind, will give SpecialtyCare customers an unmatched ability to determine benchmarks, implement best practices, and compare performance for improved medical and economic outcomes. •

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NEWS & NOTES

Advanced Wound Care Line Grows At Dynarex Dynarex, a medical supply company, has added new products to its advanced wound care line.

These include DynaRule Bullseye Measuring Guide, Retractable Tape Measure, SiliGentle AG Silver Foam Dressings and DynaSorb Super Absorbent Dressings.

DynaRule Bullseye Measuring Guide is a disposable, transparent wound measuring guide. The Retractable Tape Measure measures in both inches and centimeters and is retractable, flexible for easier readings and measures up to 72 inches (182 cm).

SiliGentle AG Silver Foam Dressings are used for a wide range of exuding wounds with delayed healing due to bacteria or where there is risk of infection. It maintains a moist wound environment to provide an optimal healing environment with an antimicrobial, sterile soft silicone foam dressing that absorbs exudate. It is indicated for management of partial and full thickness wounds, including leg and pressure

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injuries, second-degree burns, donor sites and skin abrasions.

DynaSorb Super Absorbent Dressings rapidly absorb wound exudate into super absorbent polymer core to minimize the risk of maceration and leakage, trapping wound fluids away from wound. Self-adherent style features silicone contact layer to provide gentle care for fragile skin.

The dressings are indicated for the management of partial and full thickness wounds, including leg and pressure injuries and non-infected diabetic foot ulcers.

“Dynarex demonstrates its position as the leading medical supply company in the industry by continuing to grow the advanced wound care product line,” says company CEO Zalman Tenenbaum. “We now have more than 60 products in our advanced wound care line along with hundreds of general wound care products, which exhibits our focus on continually serving the needs of our customers.” •

December 2017 | OR TODAY

11

INDUSTRY INSIGHTS NEWS & NOTES

Healthmark Offers New Solutions for Wrapped Trays Healthmark Industries is now offering Gorilla Bags as a new solution to help protect wrapped trays.

Made from spun polypropylene, the Gorilla Bags have a high tensile strength and are used as an outer protective layer applied over the standard hospital barrier packaging. The physical properties of the material offer increased resistance to tearing and splitting during transportation and storage. Due to the Gorilla Bags high permeability, they are applied before sterilization as it does not impede the steam from entering the package. Simply place the wrapped barrier package inside the Gorilla Bag, fold the lip three times, seal the bag closed with autoclave tape, and label the package appropriately for further processing. • For more information visit, www.hmark.com.

Teleflex Introduces CleanSweep Technology Teleflex Inc., a provider of medical technologies for critical care and surgery, showcased its portfolio of products for respiratory care at the 70th anniversary of the American Association for Respiratory Care (AARC) Congress, October 4-7, 2017 in Indianapolis.

At the congress, Teleflex introduced the CleanSweep Closed Suction System (CSS), a closed suction catheter designed to remain in-line for up to 72 hours. Unlike standard closed suction catheters, the CleanSweep System provides enhanced secretion removal through a dual operation of balloon sweeping technology with suction collection.

In addition, Teleflex highlighted its turnkey solution for High Flow Nasal Cannula Therapy (HFNCT), a new standard of care for patients with acute hypoxemic respiratory failure. HFNCT has grown in usage 20 percent year over year and studies published in The New England Journal of Medicine suggest treatment with HFNCT, compared to non-invasive ventilation or standard oxygen masks, can improve survival rates among patients with Acute Hypoxemic Respiratory Failure.

“Teleflex is committed to providing progressive technologies that meet the evolving needs of our customers,” said James Ferguson, president of the Teleflex respiratory division. “The introduction of the CleanSweep System highlights our dedication to connecting clinicians with technology in a way that improves clinical practice and advances patient outcomes.”•

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OR TODAY | December 2017

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INDUSTRY INSIGHTS NEWS & NOTES

Study: Prophylactic Dressings Reduce Pressure Injuries A new study shows a clear association between the prophylactic use of five-layer foam sacral dressings and reductions in pressure injury rates. Specifically, the study looked at the prophylactic use of Mölnlycke’s Mepilex Border Sacrum dressing in the acute care setting over a six-year period (2010-2015).

The study, “Effectiveness and Value of Prophylactic 5-Layer Foam Sacral Dressings to Prevent HospitalAcquired Pressure Injuries in Acute Care Hospitals – an Observational Cohort Study” was conducted by William V. Padula, Ph.D., MS, MSc; Assistant Professor, Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health. It was published in the September/October 2017 Journal of Wound, Ostomy & Continence Nursing and is available online.

The study used billing claims data to evaluate the real-world effectiveness of a prophylactic dressing at

reducing hospital-acquired pressure injury rates in 1.03 million patients treated at 38 academic medical centers and member institutions of the University Health System Consortium. No other prophylactic dressing has such extensive, real-world evidence to support its use in pressure ulcer prevention programs.

The study found significant pressure injury rate reductions following the prophylactic adoption of Mepilex Border Sacrum dressings, concluding that they were an effective component of a pressure injury prevention protocol. On average, hospitals using a typical quantity of 1-2 dressings per hospitalized patient admission experienced a 1.0 case reduction per quarter in pressure injuries identified by Patient Safety Indicator #3 (PSI-03), which is made up of Hospital Acquired Pressure Injuries (HAPI) stages 3, 4 and unstageable.

These stages of pressure ulcers are the most dangerous for patients and

the most expensive to treat.

One of the most significant findings of the study was that hospitals investing in Mepilex Border Sacrum dressings for prophylactic use at a rate of one dressing per patient made a 100 percent return on investment in less than one year (not including litigation costs). Across the study population, spending on pressure injury treatment decreased from $120/patient to $43/ patient, while investment in prophylactic dressings increased from $2.60/ patient to $20/patient.

Since the average estimated cost of a PSI-03 ranges from $50,000 to $150,000, the study reveals that the prophylactic use of Mepilex Border Sacrum dressings could save hospitals $200,000 to $600,000 per year in expenses associated with pressure injuries, as well as avoidance of CMS penalties for high hospital-acquired condition rates. •

The Pillow Factory Introduces FreshStart Personal Pillows Encompass Group LLC introduces FreshStart personal pillows through its division, The Pillow Factory.

“Our FreshStart personal pillows set the quality and performance standards for the entire industry. The breathable, non-woven covers these singlepatient-use pillows offer deliver maximum patient comfort. And fresh pillows are an ideal way for staff to address cross-contamination concerns,” said Michelle Daniels.

“Furthering our commitment to customer inventory management needs, FreshStart pillows are provided in our Case Saver program packaging-assisting in saving time, space and waste. Pillows are individually compressed, wrapped, and dispense easily from high-capacity cases. Other FreshStart pillow pluses include soft and breathable non-woven ticking, 100 percent recycled ecoCLOUD environmentally responsible fiberfill, and the ability to easily configure for propping,” she added. •

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OR TODAY | December 2017

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Castle Rock Adventist Hospital Adds Advanced Neurosurgery System

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Castle Rock Adventist is the first hospital in Colorado to acquire Synaptive’s BrightMatter technology, an innovative solution of advanced imaging, informatics, surgical planning, navigation, and robotic visualization with a digital microscope for spine and brain surgery.

BrightMatter will be used under neurosurgeon Dr. William Choi at Castle Rock Adventist Hospital. Choi is director of Precision Spine Center and a leading spine surgeon in the Denver area who has championed the use of surgical technology to improve patient outcomes. The system will allow Choi and the surgeons at Castle Rock Adventist Hospital to operate with a state-of-the-art, fully integrated solution for their expanding practice while avoiding the ergonomic challenges that come with traditional microscopes.

“Seeking emerging technology to enhance spine surgery is a long-standing passion of mine,” said Choi. “Synaptive Medical shares this interest: their BrightMatter technology offers surgeons tools with which to improve procedural accuracy and patient safety while tackling complex cases to achieve excellent outcomes. Combining robotics with nextgeneration optics enhances the surgeon’s ability to operate while leaving control in his or her hands, and will allow us to train the next generation of surgeons while viewing spine procedures in a new dimension.”

BrightMatter provides neurosurgeons with the latest advancements in visualization tools to perform minimally invasive, patient-specific approaches for both spinal and cranial procedures. For cranial procedures, using an imaging method called diffusion tensor imaging, BrightMatter automatically processes whole brain tractography for surgical planning of every possible approach. This functionality allows surgeons to see details that can’t be seen with the naked eye and may allow access to locations previously deemed inoperable. The surgical plan is integrated into BrightMatter’s navigation system, which allows surgeons to see a patient’s brain tracts in real time.

For both cranial and spine procedures, surgeons also use Synaptive’s fully automated digital microscope, a highpowered magnification system mounted on a robotic arm that automatically follows the surgeon’s tools. This replaces the need to manipulate cumbersome optics with a view the entire operating room can see with unprecedented detail, particularly for spine surgeons performing minimally invasive procedures. BrightMatter allows for better surgical ergonomics, facilitates collaboration with operating room staff, and consumes less surgical time, all factors that may lead to better outcomes. •

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INDUSTRY INSIGHTS NEWS & NOTES

Data on Novel Surface Disinfectant Presented Researchers from Case Western Reserve University and the Louis Stokes Cleveland VA Medical Center presented new data demonstrating the efficacy of Clorox Healthcare Fuzion Cleaner Disinfectant at IDWeek 2017. The study showed that Clorox Healthcare Fuzion Cleaner Disinfectant was as effective for killing Clostridium difficile (C. difficile) spores, methicillin-resistant Staphylococcus aureus, and carbapenem-resistant Escherichia coli as a standard bleach product, but was less damaging to surfaces and left less residue on surfaces.

Both bleach formulations reduced each of the pathogens by ≥6.0 log(10)CFU with a two-minute contact time. An assessment of real-world materials compatibility of the products by repeated spray applications on a hospital mattress, formica bedside table, and textiles, found that Fuzion caused minimal to no adverse effects with up to 60 applications. Personnel using the products also reported that Fuzion left much less residue after use and was more tolerable than the standard bleach product.

The research team led by Curtis J. Donskey, MD, Professor of Medicine at Case Western Reserve University and Infectious Disease Physician at the Louis Stokes Cleveland VA Medical Center, presented the findings as a poster abstract on October 5, 2017 at the IDWeek conference in SanCHANGES Diego.

PROOF APPROVED NEEDED “Contaminated surfaces are a potential source for dissemination of pathogens in the health care environment,” said Donskey.

“Our results confirm the product’s efficacy against clinically relevant health care pathogens and suggest that Fuzion may provide CLIENT SIGN–OFF: an alternative sporicidal disinfectant for facilities concerned about surface compatibility.”

Fuzion is theCONFIRM next generation of bleach andFOLLOWING the first product of its kind to combine trusted bleach efficacy against tough-to-kill PLEASE THAT THE ARE CORRECT pathogens with the aesthetics required for broad use throughout health care facilities. •

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INDUSTRY INSIGHTS AAAHC UPDATE

AAAHC UPDATES STANDARDS APPROACH

A

AAHC (Accreditation Association for Ambulatory Health Care) announced it has rewritten its Standards in advance of the 2018 Accreditation Handbook for Ambulatory Health Care publication release. AAAHC reformatted its existing standards to better demonstrate its intended meaning and simplify the self-assessment and survey processes. The revised standards will be implemented during surveys that begin on or after March 1, 2018.

The AAAHC standards were redrafted to include “elements of compliance” reflecting discrete decision points that serve as indicators of what surveyors look for to determine compliance.

Surveyors use these elements to assess how fully an organization meets the intent of each standard. The rewritten standards are more succinct and concise, presenting clear points that must be met by accredited organizations not participating in the Medicare Deemed Status program. The Standards for ambulatory surgery centers participating in Medicare deemed status will not change in 2018.

“The goal of the standards rewrite is to make survey decisions and accompanying ratings more clear and transparent, improve understanding of the standards, and simplify compliance for organizations,” said Frank Chapman, chair of the AAAHC Standards and Survey Procedures Committee (SSPC). “We implemented the revised ratings process with our health plan surveys several years ago and have 18

OR TODAY | December 2017

received a very positive response. We will now offer them to our ambulatory organizations to further improve their survey experience.”

REVISED FOR MORE CLARITY

The rewritten 2018 version of the handbook includes few entirely new or different standards, but rather presents the expectations for demonstrating compliance in a more userfriendly format.

Current standards are broad-based statements that embody many elements of compliance that determine the final ratings. To reduce ambiguity in the evaluation process, the ratings options were revised to include a chart defining what “fully”, “substantially”, “partially”, “minimally”, and “non-” compliant mean relative to the number of elements of compliance associated with each standard.

For example, Chapter 1, Patient Rights and Responsibilities, intends to emphasize patient-centeredness as essential to an accreditable organization.

For 2017, the first standard reads: 1.A Patients are treated with respect, consideration, and dignity.

The proceeding standards 1.B-E pertain to personal privacy, effective communication, patient engagement and empowerment. For 2018 standards, 1.A has not changed, but standards 1.B, C, D, and E will become the elements of compliance that more effectively describe the intended meaning of “respect, consideration, and dignity.”

Similarly, standards that previously included more than one decision point have been edited to separate each of these into a distinct element.

For example, 2017 standard 2.II.B.4 regarding confirmation of a provider applicant’s credentials using primary or secondary source verification, has been reduced from a lengthy paragraph to a more concise: Upon receipt of a completed and signed initial application, primary or secondary source verification of credentials is conducted in accordance with the organization’s written procedures for credentialing.

And the corresponding elements of compliance are clear: 1. Written procedures are present.

2. Credentials are verified using primary and/or secondary sources.

The number of “yes” responses to each element of compliance for each standard is counted and applied to a rating chart ranging from “fully compliant” to “non-compliant.” Organizations can use this chart to better understand WWW.ORTODAY.COM

AAAHC UPDATE

the standards and develop action plans for quality improvement based on their survey results and self-assessments.

“It is important to AAAHC that organizations participating in the

survey process receive input regarding the specific issues and processes included in each item of the assessment tool which can enhance the level of patient care provided by the organiza-

PROOF APPROVED CLIENT SIGN–OFF:

tion,” said David Shapiro, MD, past chair, SSPC. “AAAHC works with health care organizations when surveying them for accreditation as a means to identify areas and processes for improvement, and we wanted our standards to reflect our collegial approach to this process.”

The 2018 Accreditation Handbook for Ambulatory Health Care is currently available for purchase at www. aaahc.org/publications. Additionally, the new format has been incorporated into the curriculum presented at forthcoming AAAHC Achieving PROOF S Accreditation sessions.

CHANGES NEEDED

For more information, visit www.aaahc.org.

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December 2017 | OR TODAY

19

IN THE OR SUITE TALK

STAFF REPORT

SUITE TALK

Conversations from the OR Nation’s Listserv

TRAVELERS When travelers are used to complement staff during times of need, if a traveler is not a good fit can they be let go, or is the facility still bound to an agreement?

Is each travel contract different or are all of them pretty similar?

A: You can absolutely let them go!

A: They can be let go if they are not meeting the requirements of the position, have personality conflicts, not performing well, etc. I’ve not had any issues cx’ing someone who doesn’t work out.

A: When the individual is not as promised – doesn’t meet expectations – we have stopped service/contract. We have the right to stop service if the individual is not meeting expectations.

FLASH PANS Is it still acceptable to flash an item that was dropped/or needed for the next case? Now, facilities have (closed) pans for need back items or immediate use.

Should the open pans be taken out of service?

A: You may process a dropped item after it mitted to maintain sterility during transhas been dropped if no other like instruport to the usage point. ment is available. However, it must be sent to Sterile Processing for cleaning prior to A: No open pans. the IUSS process. Only closed pans are per-

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OR TODAY | December 2017

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SUITE TALK

STREET CLOTHES What, if anything, are you doing to identify pharmaceutical reps in the OR? We have so many reps and even though they have badges it is very difficult to know who they are. Staff feels it is unsafe and I am thinking of implementing wearing a “red” bouffant. Does anyone have any suggestions?

A: We allow one rep in a room at a time and in addition to signing into Vendor Mate they have to log themselves in and out at the nurses station and identify their purpose for their presence. But I do think a red bouffant is a great idea!

A: Our reps have to sign in to Vendor Mate and wear a red bouffant. If the rep doesn’t have a meeting scheduled in Vendor Mate,

they are not to be in the department. My boss and staff police this really well. I have seen my boss in action. He will ban them from the OR if they sneak in. Surgeons seem to like this as well. They don’t like to tell the reps no, so this process works for them also.

A: We use red bouffant hats to identify vendors.

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

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21

IN THE OR MARKET ANALYSIS

STAFF REPORT

CARTS AND CABINETS MARKETS ON THE RISE

M

edical carts and cabinets play an important role in the health care industry. They provide safe storage and transport options for a variety of medical equipment and supplies, including surgical instruments, medications and more.

The medical carts and cabinets market is a part of the larger medical furniture market and is expected to experience continued growth in the coming years.

According to a new report published by Allied Market Research, titled, “Medical Carts Market by Type: Global Opportunity Analysis and Industry Forecast, 2017-2023,” the global medical carts market was valued at $571 million in 2016, and is projected to reach $1.302 billion by 2023, growing at a compound annual growth rate (CAGR) of 12.4 percent from 2017 to 2023.

Medical cart/trolley is a mobile equipment, which consists of a set of shelves, trays, compartments, and drawers for hospital use and medical settings. It carries, dispenses, and transport emergency drugs, medicines, medical devices, and medical instruments. Carts are a crucial aspect of medical aid as it provides storing, recording, and dispensing drugs, supplies, and patient information along with patient care. Many carts are designed to supply various surgical and emergency needs depending on the operating room and other medical settings.

The emergency carts segment is anticipated to maintain its dominance, generating highest revenue throughout the forecast period, owing to the large-scale employment of emergency WWW.ORTODAY.COM

carts at the time of crisis.

This is because emergency carts contain sophisticated devices, such as defibrillators, suction devices, advanced cardiac life support (ACLS), apart from drugs, such as atropine, dopamine and others. In addition, it also includes generic drugs to treat common problems, rapid sequence intubation, and pediatric equipment.

However, the procedure carts segment is growing at the highest CAGR of 13.0 percent from 2017 to 2023 in terms of value. It consists of equipment that aids in operating procedures, such as endoscopy, cardiology and others and provides access to essential drugs at the same time.

“The need for bedside patient care in various situations, such as in operating rooms and other emergency circumstances, is expected to propel the medical cart market during the forecast period,” according to Sriram Radhakrishnan at Allied Market Research. “Innovation in functionality of medical carts that features universal mounting accessory function, RFID (radio-frequency identification), locking drawers, and dual pullout workout shelves enhance the utility of the emergency carts. Moreover, growth in health care expenditure and investments in the market have encouraged the manufacturers to develop costeffective and customized medical carts

in the developing countries boosting the market growth” North America dominated the global medical carts market, accounting for maximum share of the overall market in 2016.

The global surgical equipment/instruments market was valued at $10.5 billion in 2016 and is expected to witness lucrative growth through 2025, according to Grand View Research.

The global surgical equipment market is expected to reach $11.28 billion by 2019, according to a report from Transparency Market Research.

The growth in the global surgical equipment market will help fuel continued growth in the surgical instrument transport and storage markets.

“ The need for bedside patient care in various situations, such as in operating rooms and other emergency circumstances, is expected to propel the medical cart market during the forecast period.”

December 2017 | OR TODAY

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IN THE OR PRODUCT FOCUS

CASE MEDICAL STERITITE CASE CART SYSTEMS SteriTite case cart systems save time, money and effort. Case Medical manufactures open and closed case carts in single and double bay configurations. Designed for storage and transport, the universal sizes fit all sealed container systems and supplies. The fully adjustable perforated shelving design avoids tears when removing wrapped sets from the cart or storage shelf. Additionally, rubber wheels absorb shock and stainless-steel casters allow for easy cleaning and faster dry times. SteriTite carts have the smallest footprint relative to competitors with comparable internal storage capacity. A variety of dimensions and configurations accommodate smaller surgical sets as well as larger sets for major facilities with high volumes of “loaners.” • For more information, visit www.casemed.com.

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OR TODAY | December 2017

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PRODUCT FOCUS

HEALTHMARK DRY-BASE STERISYSTEM TRAYS Healthmark has announced the addition of Dry-Base Sterisystem Trays and Lids to its ProTech Instrument Tray product line. Manufactured from highly polished AISI 304 grade stainless steel, the DryBase Sterisystem Trays are designed to hold items during various stages of reprocessing and come outfitted with a flat base that remains in contact with condensation on wrap for better evaporation of condensate, as well as perforated side walls to facilitate effective processing of items. The stackable tray lids are equipped with four silicone corners, which are offered in four different colors: yellow, green, blue, and red. These silicone corners easily snap around the top wire of the tray to prevent small, lightweight items from falling out of the tray during processing. The Dry-Base Sterisystem Trays and Lids can be paired with the Secur-Its for Wire Bottom Baskets from Healthmark Industries that simply attach and screw into the bottom of the tray for enhanced security of items during transportation and storage. • For more information, visit www.hmark.com.

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December 2017 | OR TODAY

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IN THE OR PRODUCT FOCUS

INSTRUSAFE INSTRUMENT TRAYS Take the organization and protection of your instrument sets to the next level! Your standardization needs can be met with InstruSafe custom tray solutions that are expertly designed with you in mind. InstruSafe Trays – made of durable, highly perforated aluminum and silicone instrument holders – secure delicate instruments with 360 degrees of protection during sterilization, transportation, storage and in the OR. The trays, constructed with strong, quality materials, also reduce breakage and replacement frequencies to give your budget a break. With a variety of FDA 510(k) sterilization cycle clearances, the trays are a smart, easy upgrade for use with both wrap and rigid containers. And because the trays are fully customizable, no project is too big, small or complex. •

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OR TODAY | December 2017

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PRODUCT FOCUS

KEY SURGICAL PLASTIC STERILIZATION TRAYS Protect and organize delicate surgical instrumentation during the sterilization process with Key Surgical Plastic Sterilization Trays. Constructed of a durable polymer, the trays provide strength, durability, and chemical resistance while remaining lightweight and easy to use. Available in various sizes, each Plastic Sterilization Tray includes a silicone finger mat that can be removed for easy washing. Perforations in lid and base of tray help with steam circulation and aid in the drying process. • For more information, visit www.keysurgical.com.

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December 2017 | OR TODAY

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IN THE OR PRODUCT FOCUS

MAC MEDICAL INC. STAINLESS STEEL CASE CARTS MAC Medical Inc. manufactures a full line of stainless steel case carts that feature fully welded construction for strength and durability. Choose from several designs including open and closed case carts, and our new ergonomically friendly vertical handle case carts for instrument storage and transport. Our engineering capabilities allow us to custom design a specific case cart to satisfy any need your facility may have. • For more information, email sales@macmedical.com.

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OR TODAY | December 2017

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away while the sink does the work. It makes transporting instruments safer and makes further pre-cleaning in the SPD easier and more effective.

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IN THE OR CONTINUING EDUCATION CE614C

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OR TODAY | December 2017

BY ANITA M. HORNACKY, BS, RN, CST

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CONTINUING EDUCATION CE614C

PERIOPERATIVE PATIENT SAFETY

HYPOTHERMIA, HYPOGLYCEMIA, AND HAND-OFFS 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 37 to learn how to earn CE credit for this module.

Goal and Objectives: The goal of this continuing education program is to provide evidencebased practice guidelines that will educate perioperative caregivers in the management of three patient safety issues in the perioperative setting: hypothermia, hypoglycemia, and hand-offs. After studying the information presented here, you will be able to: • List risk factors associated with hypothermia and the interventions perioperative caregivers can perform to prevent it • List interventions for the hypoglycemic patient • Describe an effective perioperative hand-off

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Y

ou are the OR nurse caring for Marie Jenkins, an older woman scheduled for a coronary artery bypass graft. In the OR, Marie complains of being cold and is moving restlessly. You see that her temperature in the preop holding area was 37 C. You know that Marie’s age and her planned procedure put her at risk for hypothermia, so you place several warm blankets under and on top of her. Marie feels much warmer and begins to feel less anxious. You give the anesthesia provider a temperature probe and remind him that there’s a new IV fluid warmer available if he should need warmed fluids. Marie has diabetes, so you check her latest blood glucose level and communicate it to the team. During induction, Marie reports she is warm and comfortable. You have used your evidence-based knowledge to help your patient.

More than 54.1 million people undergo surgery in hospitals annually in the U.S., according to the Centers for Disease Control and Prevention (CDC).1 Many patients suffer from preventable events that put them at risk for injury and death when perioperative team members lack knowledge to prevent negative outcomes and do not follow evidence-based practice (EBP).

Treatment of surgical site infections (SSIs) costs about $3.3 billion annually.2 The Joint Commission has put into place a National Patient Safety Goal to provide guidance on preventing SSIs. In 2002, the Centers for Medicare & Medicaid Services (CMS)

in collaboration with the CDC implemented a program called the National Surgical Infection Prevention Project (SIP). This program sets guidelines to help prevent SSIs.3 From the SIP evolved the Surgical Care Improvement Project (SCIP) in 2006. These measures help track compliance with national standards. The measures are based on EBP and promote prevention of SSIs and optimal management of hypothermia, hypoglycemia, and hand-offs in the perioperative setting.3 PROBLEMS IN CURRENT PRACTICE

Many of the millions of people who December 2017 | OR TODAY

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IN THE OR CONTINUING EDUCATION CE614C undergo surgical procedures each year suffer from preventable events or complications. A systematic review of the literature, published in 2013, found 14.4% of surgical patients experienced an adverse event, with 5.2% of the events considered potentially preventable.4 The federal government and organizations such as the World Health Organization, Association of periOperative Registered Nurses (AORN), CMS, CDC, and The Joint Commission have taken steps to promote patient safety by establishing patient safety goals.

National patient safety goals are more than an attempt to standardize perioperative patients’ care. They serve as guidelines that have reduced the number of adverse events.

WHO has established a 19-item surgical safety checklist that has showed a reduction in morbidity and mortality around the world.5 Other organizations, such as AORN, have adopted the checklist and modified it to fit their individual needs, such as The Joint Commission’s universal protocol.6 The World Federation of Societies of Anaethesiologists urges practitioners to follow the International Standards for Safe Practice in Anesthesia.7 These organizations base their guidelines on EBP, which serves as the underlying rationale for appropriate actions and is the key to safe practice.

This module covers the three “Hs” of potential adverse effects: hypothermia, hypoglycemia, and hand-off miscommunication. Each topic includes an overview of EBP information that healthcare providers can apply to reduce patients’ risk of suffering harm from these events. The ability to apply the information depends on a solid understanding of EBP in the perioperative setting.

rates the best evidence from research.

This research is evaluated for proof that supports the rationale for actions. Studies are constantly being conducted, and new research comes out of those studies. Every healthcare provider should question why an action is performed and if there is a better or safer way of completing a task based on new research and supporting evidence. Many healthcare providers complete tasks out of habit. Many of the old practices are no longer supported by current data. The fast-paced environment of the preoperative area, OR, and PACU allow little time for healthcare providers to seek evidencebased information. Nurse educators need to keep current on the latest research and help implement it in daily practice.

Questioning practice and determining if there’s a need for change begin the process of EBP. Asking a clinical question about a practice and searching for research-based resources increase knowledge and help with critical evaluation of the evidence for usefulness and importance in the perioperative setting. After completing the analysis, designing a clinically applicable plan is the next step. Change is never easy and needs support from healthcare providers, who must be committed to the change. Administrators may need to provide evidence and additional resources, such as new products, equipment, specialized employee training, or additional personnel. To maintain its implementation, all staff members, including physicians and anesthesia providers, must support the new change. EBP is not exclusive to any one of the settings, but it encompasses all of them, and everyone plays a vital role in its promotion.

EVIDENCE-BASED PRACTICE

A common complication of surgery is hypothermia. It is the reduction of core body temperature to 36 C (96.8 F)

EBP is a problem-solving approach to the delivery of care that incorpo32

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H = HYPOTHERMIA

or lower.8,9 The hypothalamus is responsible for the regulation of body heat. A long-term study of 143,157 noncardiac patients from April 2005 to February 2013 at the Cleveland Clinic documented that core temperature declined in the first hour of anesthesia and increased thereafter. Sixty-four percent of patients reached a core temperature below 36 C within 45 minutes after induction. Nearly 29% reached a core body temperature of below 35.5 C. Only 7.3% of patients had core body temperatures less than 35 C at 71 minutes. The study found that 91% of patients warmed with forced air had core temperatures above 36 C by the end of the surgical procedure.8 For the surgical patient, hypothermia can be traced to heat loss related to the cold surgical environment, the effects of anesthesia-induced thermoregulation impairment (general and regional anesthesia), prolonged exposure of skin, cold prep solutions, and draping leaving skin exposed.9 Hypothermia can lead to potential myocardial complications, coagulopathy, surgical wound infections, reduced drug metabolism (including muscle relaxants), and prolonged recovery.8,9 Hypothermia is associated with increased mortality in trauma patients, often due to blood loss, exposure to cold at the scene, and rapid infusions of cool fluids. The hypothermia leads to coagulopathy and acidosis.9 Burn patients lose body heat from burned tissue exposed to air currents. Frail older adults are at greater risk than younger, healthier patients because they lose heat more quickly due to decreased fat or muscle mass or thermoregulatory inabilities. However, infants are a greater risk due to their high body surface area to weight ratio, which can result in more heat lost through the skin.9 In one study, patients undergoing elective procedures had twice as many WWW.ORTODAY.COM

CONTINUING EDUCATION CE614C

complications and were at four times’ greater risk of dying. Strokes and sepsis increased the most in this study.10 WHO IS AT RISK FOR HYPOTHERMIA?

• • • • • • • • •

Older than 55 with body mass index of less than 258 Preoperative hemoglobin level of less than 1.4 g/dL8 Surgery lasting more than four hours8 Anemia10 Chronic renal impairment10 Weight loss without trying10 Severity of illness10 Males10 Neurologic disorders10

Factors influencing the severity of potential hypothermia include: • Low body weight, due to limited insulation and a large body surface to weight ratio • Metabolic disorders that limit heat production or a proper response to ambient air temperatures • Antipsychotic or antidepressant use because they impair thermoregulation • Pneumatic tourniquet use after it is released and heat from the core moves to the extremity • Temperature in the surgical environment because heat is lost through radiation, convection, and evaporation of skin preps • Open-cavity surgery in a cool environment • Infusion of cold fluids or blood • Irrigation with cool solutions as heat transfers to the solution from the body NURSING ACTIONS ACROSS THE SPECTRUM OF CARE

A team effort is needed to minimize hypothermia’s negative outcomes. In the preoperative area, the nurse can assess a patient’s risk of hypothermia WWW.ORTODAY.COM

by evaluating vital signs, laboratory results, type of anesthesia, and general health status. SCIP measures require the preoperative nurse to record the patient’s temperature and warm patients before surgery based on the latest research. The nurse can minimize hypothermia by providing warm cotton blankets if a forced air gown or blanket is not available.

AORN recommends that patients should be warmed with an active warming device with forced air. AORN has a Prevention of Perioperative Hypothermia Tool Kit. This guide describes the steps to be taken to prevent perioperative hypothermia.11 The OR nurse can minimize heat loss by warming the room temperature for neonates and infants to at least 26 C (78.8 F) and for other at-risk patients and trauma patients to 29.4 C (85 F).12 This may be uncomfortable for the surgical staff, but it will reduce the likelihood of hypothermia at the start of the procedure. Once the patient can be actively warmed, the room temperature may be adjusted if the patient is normothermic. It is good practice to keep the patient covered as much as possible to retain heat as well as dignity.

One of the best active warming devices is the forced-air gown or blanket.

Special gowns contain a hole where a hose can fit to deliver warm air from a machine. Many ORs have special body warming drapes that work the same way but may be positioned according to the surgical site. Care must be taken not to let the hose come into contact with the patient’s skin because it can get very hot and burn the patient. It is not a recommended practice to warm the OR bed with a forced air blanket or hose placed under the sheet before the arrival or draping of the patient.

This practice stirs up contaminates in the air that may contribute to SSIs. In some cases, when a large area of skin is exposed, the recommendation

may be to use a warm-water mattress on the bed, which the patient will lie on during the procedure. When using any warming device, be sure to follow the manufacturer’s directions and assess the patient’s skin, because burn injuries can occur related to vasoconstriction.9 Observation of temperature is done in conjunction with the anesthesia provider, who can obtain continuous intraoperative core temperature measurements, depending on the type of surgery, by oral, skin, temporal artery, axillary, rectal, pulmonary artery, distal esophagus, tympanic membrane, nasopharynx, bladder, or needle probe. The anesthesia provider and circulating nurse can provide warm fluids through IV or delivered warm to the scrub person. Fluids should be near body temperature. Special basin fluid warmers are available for long cases; care must be taken because fluid warmers have multiple settings that go as high as 43.3 C or 110 F. The patient can be internally burned by hot irrigation fluids. Some nurses have used warm bags of saline placed under the armpits of patients to warm them. This is not a recommended practice, because it can cause burns. In trauma patients, extreme active warming can be done by heated humidified oxygen, warm irrigation through peritoneal lavage, dialysis, and heated cardiopulmonary bypass.9 In the PACU, warm blankets/ forced-air blankets, brought with the patient from the OR, help maintain continuity of care. Most patients come to the PACU normothermic if the recommended guidelines and policies are followed. Every facility should now have a policy based on EBP, SCIP, AORN, and Joint Commission recommendations.

H = HYPOGLYCEMIA

According to the CDC, 29.1 million people, or 9.3% of the U.S. population, December 2017 | OR TODAY

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IN THE OR CONTINUING EDUCATION CE614C have diabetes, and many others remain undiagnosed.13 Diabetes is a chronic metabolic disease that affects the way the body processes blood glucose. It is classified as hyperglycemia (high blood glucose) related to the defect in the production of insulin, and in the case of type 2, insulin resistance. The classic diagnostic criteria are fasting plasma glucose greater than 126 mg/ dL, random glucose checks of more than 200 mg/dL, a two-hour postprandial glucose tolerance test of 200 mg/ dL or greater, or a hemoglobin A1C greater than 6.5%.14 The Standards of Medical Care in Diabetes, 2016, recommends target premeal blood glucose of 80-130 mg/ dL and an A1C of less than 7%, with more or less stringent goals depending on the patient.14 Several categories of diabetes exist, including type 1, type 2, gestational, and diabetes due to other causes.14 Type 1 is an autoimmune disease and leads to the destruction of the B-cells and total insulin destruction. These patients must monitor their glucose often throughout the day and inject insulin several times a day according to their blood glucose level. Some patients have a small insulin pump that delivers basal insulin 24 hours a day and covers carbohydrate intake with additional short-acting insulin. A small catheter under the skin is attached to a pager-sized device. It can be programmed automatically to release insulin into the system. The device has a disconnect port for swimming, showering, or other water-related activities.

Type 2 diabetes is the most common, accounting for 90% to 95% of all cases. With type 2, the pancreas makes insulin to get glucose into the cells. The body does not use the insulin correctly or not enough insulin is produced, causing the glucose to build up in the blood.

Hypoglycemia occurs when the blood glucose levels drop to 70 mg/ 34

OR TODAY | December 2017

dL or less. Too little food, fasting before surgery, intense exercise, or too much diabetes medication can cause a patient’s blood glucose level to drop to this level. Patients on insulin and oral glucose-lowering drugs can experience hypoglycemia, adverse reactions, injury, accidents, unconsciousness, seizures, brain damage, and death. Injuries and accidents can occur as a result of confusion, weakness, and motor deficits. Patients become susceptible to falling and loss of consciousness due to low levels of glucose.14 CMS has made hypoglycemia resulting in death or serious disability while in a healthcare facility a “never event.”15 Signs and symptoms vary: Glucose is a source of fuel for the human body and a critical element for brain function. Relationship between blood glucose levels and hypoglycemia signs and symptoms vary from person to person and can differ in the same person depending on circumstances.

Patients with low blood glucose levels may have mild symptoms, such as sweating, trembling, light-headedness, restlessness, confusion, irritability, and hunger. Patients with hypoglycemia unawareness may have no symptoms.

This variation makes close monitoring and prompt treatment vital.

Studies have shown that excellent outcomes are increased when blood glucose levels are maintained between 80 and 180 mg/dL14 during the perioperative period and from 140 to 180 mg/ dL during the postoperative period.16 PERIOPERATIVE MANAGEMENT OF PATIENTS WITH DIABETES

Guidelines help healthcare providers combat hypoglycemia. The guidelines include how to recognize and treat the patient when signs and symptoms become apparent. But nurses should not wait for symptoms. Blood glucose should be checked every four to six hours while the patient is NPO.14 Preoperative blood glucose moni-

toring may prevent negative surgical outcomes, promote wound healing, and reduce mortality and morbidity.

Continuity of blood glucose monitoring by inpatient bedside blood glucose measurement systems can help prevent complications.16 Surgical procedures can cause a patient’s blood glucose level to become too high or too low. Surgery puts stress on the body, and the addition of anesthetic drugs may affect the metabolism of glucose.16 Guidelines reported in “Surgical Residency Practice” state that postop patients with mild hypoglycemia symptoms and blood glucose of less than 70 mg/dL should be treated with a dextrose infusion. This treatment is repeated until blood glucose is above 70 mg/dL. Studies have shown that surgical patients did better, with fewer complications, when intraoperative glucose levels were maintained within 140 to 170 mg/dL.16 The target glucose level for stable patients’ levels should be less than 140 mg/dL and for critically ill patients less than 180 mg/dL. During surgery, glucose levels of less than 140 mg/dL and greater than 200 mg/dL are associated with a significant risk for complications, morbidity, and mortality. Hospitals have set different higher-end glucose levels for cancelling surgery, such as greater than 400 mg/dL at Yale New-Haven Hospital in Connecticut and greater than 500 mg/dL for nonurgent procedures at Boston Medical Center.16 Once surgery is completed and the patient is in the PACU, blood glucose levels should be managed between 140 and 180 mg/dL until the patient is stable enough to transition into the presurgical regimen.16 Goals of 110 to 140 mg/dL may be appropriate for certain patients, such as cardiac patients, if the tighter control does not lead to hyperglycemia.14 American Diabetes Association guidelines recommend giving the WWW.ORTODAY.COM

CONTINUING EDUCATION CE614C

hypoglycemic patient who is conscious and out of surgery 15 g to 20 g of carbohydrate that contains glucose, then monitoring, and repeating if the glucose level remains low after 15 minutes. The patient should then eat a snack or meal.14 Each hospital and outpatient clinic should have its own hypoglycemia guidelines and policies in place based on recommendations from recognized organizations and government agencies to improve surgical outcomes.

H = HAND-OFF COMMUNICATION

Improving the effectiveness of communication among caregivers, including perioperative team members, is a safety goal of several agencies. The Joint Commission has developed the Targeted Solutions Tool for Hand-off Communications. It includes using a standardized form, identifying and stressing key information, and conducting the hand-off in a quiet zone.17 AORN also has created a Webbased tool kit to help healthcare providers standardize hand-off communications. It is based on the U.S. Department of Defense’s TeamSTEPPS program.18 A key part of perioperative communication is the hand-off: a report from one member of the team to another to ensure continuity of care. To be of value, a hand-off should be accurate and clear. Specific standardized protocols are recommended because the handoff is associated with communication breakdown and sentinel events.17 ONGOING COMMUNICATION

Hand-off takes place at each stage of the perioperative process, starting with the preoperative area. The nurse obtains important information to communicate to the OR nurse. This includes identifying the patient using a double identifier of name and birthday or name and medical records number, verifying the consent has been signed, WWW.ORTODAY.COM

obtaining vital signs, and assessing patient understanding. Other important information is history and physical results, NPO status, medications taken, laboratory test, allergies, and surgical site marking.

Before surgery, the OR team discusses the plan of care and conducts a timeout before the incision is made.

The timeout includes verification of correct patient, signed consent, surgical procedure, site marking, NPO status, allergies, antibiotics and other medications given, relevant images, and implants. Each member plays a vital role in the communication process.

Once the surgical procedure is completed, the OR nurse communicates to the PACU nurse. Patient identification, history, procedure, medications given, how the procedure was tolerated, fluids given, type of anesthesia, estimated blood loss, oxygen saturation, urine output, complications, hemodynamic stability, and current level of pain are included in the report. In turn, the PACU nurse communicates similar information when transferring the patient to another area.

The method of hand-off should be standardized and easy to use. Structured tools can help ensure consistency, for example, the SBAR format.19 Hand-off reporting improved when employees were educated about the policies and standardized protocols were in place. Protocols can include a checklist and written, verbal, and electronic documentation formats.17 Effective standardized communication facilitates a safe environment, positive outcomes, and continuity of care.

Keeping the patient safe from hypothermia, hypoglycemia, and hand-off miscommunication is part of the healthcare team’s role as a patient advocate. Nurses, both individually and as a team, should periodically assess evidence in the three “Hs” to ensure their practice is congruent with the latest findings and to make modifica-

tions as needed. Doing so is part of a nurse’s role as a patient advocate.

EDITOR’S NOTE: Sophia Mikos-Schild, EdD, MSN, RN, MAM/HROB, CNOR, the original author of this continuing educational activity, has not had the opportunity to influence this version.

OnCourse Learning guarantees this educational activity is free from bias.

Anita M. Hornacky, BS, RN, CST, is a perioperative educator for pharmacology and a clinical instructor for the Surgical Technology Program at Lakeland Community College, Kirtland, Ohio.

References 1. Inpatient surgery. Centers for Disease Control and Prevention Web site. http:// www.cdc.gov/nchs/fastats/inpatientsurgery.htm. Accessed June 28, 2016.

2. Zilmichman E, Henderson D, Tamir O, et al. Healthcare-associated infections: a meta-analysis of costs and financial impact on the U.S. health care system. JAMA Intern Med. 2013;173(22):2029-2046. doi: 10.1001/ jamainternmed.2013.9763.

3. Rosenberger LH, Politano AD, Sawyer RG. The surgical care improvement project and prevention of postoperative infection, including surgical site infection. Surg Infect. 2011;12(3):163-168. doi: 10.1089/sur.2010.083.

4. Anderson O, Davis R, Hanna GB, Vincent CA. Surgical adverse events: a systematic review. Am J Surg.

2013;206(2):253-262. doi: 10.1016/j. amjsurg.2012.11.009.

5. WHO surgical safety checklist. World Health Organization Web site. http:// www.who.int/patientsafety/safesurgery/ checklist/en. Published 2009. Accessed June 28, 2016.

6. AORN comprehensive surgical checklist.

Association of periOperative Registered Nurses Web site. https://www.aorn.org/ aorn-org/guidelines/clinical-resources/ tool-kits/correct-site-surgery-tool-kit/ aorn-comprehensive-surgical-checklist.

Accessed June 28, 2016.

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IN THE OR CONTINUING EDUCATION CE614C 7. Safe standards in international anasethesia. The Association of Anaesthetists Web Site. https://www.aagbi.org/ international/international-relationscommittee/international-standardsanaesthesia. Accessed June 28, 2016.

8. Sun Z, Honar H, Sessler DI, et al.

Intraoperative core temperature patterns, transfusion requirement, and hospital duration in patients warmed with forced air. Anesthesiol. 2015;122:276-285. doi: 10.1097/

ALN.0000000000000551.

9. Guideline for prevention of unplanned patient hypothermia. In: Burlingame B, Benholm B, Link T, et al. Guidelines for Perioperative Practice. Denver, CO: AORN; 2015.

CLINICAL VIGNETTE Karen Summers, age 69, is in the preoperative holding area before her scheduled total abdominal hysterectomy. She has type 2 diabetes treated with oral hypoglycemic and regular insulin and has an IV. Her vital signs are 132/78 mmHg blood pressure, 37 C temperature, 86 pulse, and 18 respirations. She has had nothing by mouth and taken only sips of water to swallow her medications. She appears thin and responds slowly to questions. She says she feels “chilly.” Soon, Karen begins to complain of a headache, vertigo, and drowsiness. She becomes pale and has difficulty speaking. She is able to state that she did not eat but took her oral medications. The preoperative holding area nurse obtains a blood glucose level per protocol.

4. Correct Answer: A, Unintended hypothermia is the reduction of core body temperature to 36 C or lower. Karen is at risk for hypothermia because of anesthesia and the fact that she is having a major surgical procedure.

3. Correct Answer: C, The hand-off should be standardized and easy to use so it’s more effective. A tool can be used to help standardize the hand-off. Hand-offs should be concise and without interruptions. Questions should be addressed at this time.

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4. In the OR, the nurse will know that Karen is experiencing hypothermia if her temperature is ____ or lower.

A. 36 C C. 38 C B. 37 C D. 40 C

1. Correct Answer: B, Hypoglycemic signs and symptoms vary in patients with diabetes and must be monitored closely. Body temperature must be at least 36 C to prevent inadvertent hypothermia. Too little food and/or too much hypoglycemic medication can cause a patient’s blood glucose level to drop below normal.

2. Karen’s blood glucose level comes back as 40 mg/dL. Which is an appropriate hypoglycemia protocol order?

A. Administer 50% dextrose B. Administer 15 g of carbohydrates C. Repeat the blood glucose in 90 minutes D. Repeat the blood glucose in 60 minutes

3. The preoperative holding area nurse communicates what occurred with Karen to the OR nurse. Which would make the handoff more effective?

A. Not using the same hand-off tool for each communication B. Providing information that is extremely detailed C. I mplementing a standardized tool that is easy to use D. Not including time for questions to avoid delays in patient care

2. Correct Answer: A, Patients who are unable to swallow and have more advanced symptoms (like Karen) are typically treated with 50% dextrose IV. Glucose levels should be retested according to facility policy after dextrose administration.

1. Given Karen’s history and planned surgery, the PRIMARY assessment areas for the preoperative holding area nurse include: A. Whether Karen has a family member with her B. Temperature and signs and symptoms of hypoglycemia C. Karen’s cultural background D. Reflex responses

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10. Billeter AT, Hohmann SF, Druen D, Cannon R, Polk HC Jr. Unintentional perioperative hypothermia is associated with severe complications and high mortality in elective operations. Surg. 2014:156(5):1245-1252. doi: 10.1016/j.surg.2014.04.024.

11. Prevention of perioperative hypothermia (PPH) tool kit. Association of periOperative Nurses Web site. https://www.aorn.org/guidelines/clinical-resources/ tool-kits/prevention-of-perioperative-hypothermiapph-tool-kit. Accessed June 28, 2016.

12. Prevention of inadvertent perioperative hypothermia.

Pennsylvania Patient Safety Advisory. 2008;5(2):4452. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Jun5(2)/Pages/44.aspx. Accessed June 28, 2016.

13. National diabetes statistics report, 2014. Centers for Disease Control and Prevention Web site. http://www. cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf. Accessed June 28, 2016.

14. American Diabetes Association standards of medical care in diabetes — 2016. Diabetes Journals Web site. http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standardsof-Care.pdf. Accessed June 28, 2016.

15. Eliminating serious, preventable, and costly medical errors — never events. Centers for Medicare & Medicaid Services Web site. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2006Fact-sheets-items/2006-05-18.html. Published May 18, 2006. Accessed June 28, 2016.

16. Sudhakaran S, Suran SR. Guidelines for perioperative management of the diabetic patient. Surg Res Pract.

2015;2015:284063. doi: 10.1155/2015/284063.

17. Hand-off communications. Joint Commission Center for Transforming Healthcare Web site. http://www. centerfortransforminghealthcare.org/projects/detail. aspx?Project=1. Accessed June 28, 2016.

18. Patient hand-off/over tool kit. Association of periOperative Registered Nurses Web site. https://www.aorn. org/guidelines/clinical-resources/tool-kits/patienthand-off-tool-kit. Accessed June 28, 2016.

19. Transitions of care: the need for a more effective approach to continuing patient care. The Joint Commission Web site. http://www.jointcommission.org/ assets/1/18/hot_topics_transitions_of_care.pdf. Accessed June 28, 2016.

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IMPROVIN and Performance

NG EFFICIENCY

By Don Sadler Surgical services are a key component of revenue for hospitals today. At better performing hospitals, 68 percent of revenue comes from surgery. In other words, the financial success of most hospitals depends on the smooth operation of the OR. Given this, it’s kind of surprising that surgical services has undergone very little operational change in over a century. Hospitals that want to improve financially need to take a hard look at their processes and procedures in an effort to boost overall efficiency and performance.

ANTIQUATED PROCESSES LEAD TO INEFFICIENCY

“The surgical processes typically followed tend to be very antiquated,” says Jeffry Peters, the CEO of Surgical Directions in Chicago, Illinois.

He offers an example of this and the resulting inefficiency.

“Patients are interviewed by a nurse prior to surgery and then asked the same questions again by the anesthesiologist and surgeon,” says Peters. “That’s three different patient interviews because OR staff aren’t talking to each other.”

Peters notes that the vast majority of procedures today are ambulatory surgeries.

“So the ability to perform ambulatory surgeries in a quality and efficient manner is critical to the success of health care organizations,” he says.

Jan Davidson, MSN, RN, CNOR, CASC, the director of the Ambulatory Surgery Division of the Association of periOperative Registered Nurses (AORN), says that ASCs are efficient by nature.

“If they weren’t, they wouldn’t stay open,” she says. Davidson says the Centers for Medicare & Medicaid Services (CMS) is considering removing total knee arthroplasty and total or partial hip arthroplasty from the inpatient-only list of procedures approved for reimbursement. This would result in even more total joint replacements being performed in ambulatory surgeries.

“However, many third-party pay-

ers are already reimbursing ASCs for these and facilities have shown to have excellent clinical outcomes,” she adds.

OPTIMIZING PATIENTS BEFORE SURGERY

One of the keys to increasing efficiency in hospitals, says Peters, is planning well in advance for surgical procedures and optimizing patients before surgery.

“For example, there should be a pre-anesthesia process where you talk to patients to find out about all of their comorbidities, such as diabetes and hypertension, so these can be managed prior to surgery,” he says. “If you don’t, this will result in surgical delays.”

Peters also recommends a daily huddle between nursing and anesthesia personnel to review all patients and procedures days before surgeries are scheduled.

“The most efficient health care organizations track metrics like on-time first case starts, same-day cancellations and turnover time,” adds Peters. “They implement initiatives to improve these metrics, which increases efficiency and helps drive better performance.”

“Profitability is linked hand-in-hand with efficiency, performance and patient outcomes,” adds Davidson. “In an ASC, profit is based solely on surgical volume and an equitable reimbursement from third-party payers. Greater efficiency equates to more volume.”

Surgery is a team, not an individual, sport so you have to get everybody on the same page.

JEFFRY PETERS, CEO, Surgical Directions

THE VALUE VS. VOLUME EQUATION

According to Peters, value is now replacing volume as the key buzzword in hospitals as payers base a portion of payment on achieving positive clinical outcomes. He notes that CMS will require that half of payments be value-based by 2018.

“Health care organizations are penalized for things like high readmission rates, surgical site infections and the like,” he says. “Simply put, you’re not going to get all the money you should if you don’t have good outcomes.”

“Value-based reimbursements is a win-win for everyone: the patient, the health care provider and the thirdparty payer,” says Davidson.

Peters lists a number of common characteristics shared by successful health care systems’ perioperative services: • A collaborative governance structure • The sharing of transparent and comprehensive information • Engaged involvement by surgeons, nurses and administrative leadership • A focus on new and innovative models to deliver care, such as surgical home and bundled payments • Implementation of processes to enhance OR efficiency, such as faster turnover times, ontime case starts and shorter case times • Lower overall costs • An uncompromised focus on achieving clinical excellence Peters recommends forming a surgical services executive committee to help ensure collaborative governance. The committee should consist of representatives from surgical, perioperative nursing and anesthesia leadership, as well as senior leadership of the health care organization.

“Surgery is a team, not an individual, sport so you have to get everybody on the same page,” says Peters. “This perioperative governing body will help align incentives and serve as an

IMPROVING EFFICIENCY and Performance

Jeffry Peters,

CEO of Surgical Directions

operating committee for all aspects of perioperative services.”

NUDGING SURGEONS TO BETTER PERFORMANCE

Of course, surgeons play a big part in improving OR efficiency and performance. Andi Dewes, the chief nursing officer at Ayus Inc., in Waconia, Minnesota, says there are a number of things health care organizations can do to help nudge surgeons toward better performance.

“Surgeons make lots of choices that affect efficiency,” says Dewes. “For example, will they show up on time and schedule their cases in block? Or, will they minimize elective add-ons and use on-contract implants?

“If they don’t, it’s a conscious choice they make,” she adds.

“So the goal should be to design choices that alter surgeons’ behavior in a predictably positive way without forbidding any safe options or significantly altering surgeons’ economic incentives.”

Dewes lists a number of predictable mental biases that often affect the decisions and choices surgeons make. One of these is what she calls anchoring, which is a bias toward the initial piece of information we are given. All other judgments are

Jan Davidson,

MSN, RN, CNOR, CASC, Director of the Ambulatory Surgery Division of (AORN)

then made by adjusting away from this “anchor.”

“In the OR, anchors are things like eight-hour blocks, a 10-minute grace period for late starts or a 90-minute window for cases,” she explains. “Let surgeons set their own anchors – such as by setting their own targets or goals – and then nudge them in this direction.”

Another mental bias mentioned

by Dewes is availability, which is a tendency to overestimate the likelihood of events that have happened most recently or carry the most emotional weight.

“For example, maybe an instrument was missing during a surgery yesterday which caused the procedure to run late,” Dewes explains. “So the surgeon thinks that missing instruments are a big problem, when in reality this happens very infrequently.”

The key to combatting this bias is providing surgeons with updated and current information regarding the actual probabilities of certain events.

“Regularly highlight information that may challenge their established beliefs,” says Dewes. “Be attentive to outliers, but don’t give them more attention than they deserve.”

Yet another mental bias common

Andi Dewes,

Chief nursing officer Ayus Inc.

among surgeons is loss aversion.

This is the human tendency to prefer avoiding losses (by a factor of at least two to one) to acquiring gains.

“In the OR, this might take the form of threats or negative language toward surgeons about losing block,” says Dewes.

“Surgeons don’t tend to respond well when threatened,” she adds. “Instead of communicating with surgeons punitively, speak with them using positive language emphasizing the community of surgeons, staff and the administration working together collaboratively.”

ALL DOWN THE SURGICAL SERVICES LINE

Peters says that hospitals are looking to OR leadership to improve management of the surgical services line financially, operationally and clinically.

“Your goal should be to be viewed as the health care provider of choice for meeting both patients’ and surgeons’ needs,” he says. “Improving efficiency and performance is the key to accomplishing this.”

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BY M AT T S KO U FA LO S

SPOTLIGHTON

Susan Boral, RN, BSN

A

fter undergoing open-heart surgery as a teenager, Susan Boral thought she might someday enter the health care field. Instead, she pursued a degree in environmental science. After graduation, she still felt the pull of nursing. Boral found her interest redoubled after joining a local EMT squad. In 2000, when the job market “wasn’t so great” for environmental scientists, she made a career change.

“I always wanted to help people, but what attracted me to the medical field is the science part of it,” she said; “anatomy, physiology, how our interventions affect the body. It’s the desire to help society [and] the desire to be part of a team.”

Boral signed on to the accelerated career entry (ACE) program at Drexel University in Philadelphia, an 11-month, change-of-career path for bachelor’s-degreed students that she described as a nursing boot camp. It was one of the first alternative nursing tracks in her area. Boral remembered it as very challenging for the intensity of its instruction within a compressed timeline. Yet it didn’t require half the adjustment she made jumping into her first assignment in the emergency room.

“I had a background in EMT, so I had been exposed to [trauma care],” Boral said, but the ER is “that next level.”

“You do more of an investigation,” she said. “It’s exciting. It’s fun to dig deep and figure out exactly what’s

46

OR TODAY | December 2017

going on, and use all my knowledge and resources to get to the bottom of something.”

As an EMT, Boral had been charged with stabilizing patients outside of the hospital environment and handing them off to a nurse; in the ER, she found herself on the admissions side of triage, delivering higher levels of care and diving deeper into

“ I ALWAYS WANTED TO HELP PEOPLE, BUT WHAT ATTRACTED ME TO THE MEDICAL FIELD IS THE SCIENCE PART OF IT.” B O R A L

SUSAN BORAL diagnosing ailments. Boral started working overnights at Our Lady of Lourdes Hospital in Camden, New Jersey, which at the time was one of the most violent cities in the country.

Working collaboratively was important to the success of the unit, and the physicians with which she worked greatly respected their nurses, which made her feel comfortable in a highstress job. “[Doctors] relied on us to be their eyes and ears,” Boral said; “[they relied] on a good, strong nursing team to point out things to them, [and to] sort out what’s an emergency versus what can wait. They encouraged autonomy and teamwork.”

Boral’s superiors also encouraged her to advance her schooling, to earn additional degrees, and to take on WWW.ORTODAY.COM

leadership roles within the hospital.

When she switched from overnights to mid-shift, that opened up an opportunity to take on a per-diem role in the MedCom department, which provides standing orders for paramedics. Boral described the assignment as “a lot of downtime interspersed with moments of excitement.”

“Every shift was different,” she said.

Boral worked in the ER for about 12 years before she was offered her current position at Thomas Jefferson University Hospital, a high-volume teaching hospital in Philadelphia, Pennsylvania. She’s spent the past five years working a daytime shift in its employee and student health division.

Although the work isn’t as highintensity as EMT or ER triage, it plays a vital role in infection control and population health, and Boral is part of a small department in a large, rapidly changing institution.

“As much as I loved ER nursing, it was exhausting and I wanted to try something else,” Boral said. “We’re responsible for keeping our employees, students, patients, and volunteers safe and healthy. It’s protecting [our staff ], and protecting our patients, and making sure that they’re physically capable to do their job. It’s a different type of nursing.”

Her roles and responsibilities have

JIM & SUSAN BORAL “I feel like I spend a significant amount of time on the computer rather than talking directly face to face with my patient,” Boral said. “The need to constantly look at your phone also makes it difficult for a patient to stay present. It’s a new challenge we face to keep the patient engaged.”

To help stay connected to her body and mentally fresh, Boral also became a certified spin instructor. She said the relief she feels from keeping fit is a personal priority as well as an outlet for the stresses of her life. Simply put, taking care of herself gives her the groundwork she needs to be able to care for others.

“It’s important to make sure that you maintain your sense of self as a nurse,

“ NURSING HAS MADE ME A VERY RESILIENT PERSON; IDEALLY, A GRATEFUL PERSON. I CAN HANDLE ANYTHING.” B O R A L evolved with her time in the nursing field, Boral said, but she doesn’t let the increasingly digital demands of her job overtake her focus on bedside manner. Being mindful, present, and maintaining the human component of caregiving is one of the biggest challenges she faces – and the digital divide has two sides WWW.ORTODAY.COM

because you get completely consumed by it some days when you’re working,” Boral said. “Don’t let your hobbies, health, and relationships suffer because you’re having a rough day at work.”

For as much as her careers in nursing and emergency medicine have intersected throughout her life, no moment may have been as significant as

Susan Boral is seen with her Bike MS City to Shore Ride medal after participating in the National Multiple Sclerosis Society event.

Susan Boral makes time away from work for exercise and other activities to help relieve the stresses that come with being a nurse.

the visit she paid New York City 10 days after the September 11, 2001 attacks.

Being at Ground Zero to run support work for the EMT squads “was almost like an out-of-body experience,” Boral said. She described the eerie stillness of the typically lively neighborhoods nearby as feeling “like a post-apocalyptic scene,” and remembered the fine dust from the tragedy that coated everything.

“It’s hard to accept the reality of what happened until you saw it firsthand,” Boral said. “It was a lesson in doing your job despite what you were feeling, despite what was happening around you.”

It was also a formative moment in a career that requires the ability to separate emotional reactions from training, and for Boral, it was an experience that will never leave her mind.

“Nursing has made me a very resilient person; ideally, a grateful person,” she said. “I can handle anything.”

December 2017 | OR TODAY

47

OUT OF THE OR FITNESS

BY MARILYNN PRESTON

YOUR BRAIN

LOVES TO DANCE I

t’s one thing to lose your keys, your phone, a wallet filled with credit cards. It’s wildly upsetting, but it’s all stuff you can get back. But losing your mind? Losing your memory? Your thoughts, in mid-stride, so you have to double back and ask yourself where was I going with that story about the guy I met in yoga class who has the apricot-colored poodle?

It happens to everyone – kids forget stuff, too – but I don’t like it. And one reason is that I know the mind is like a muscle. Use it or lose it. Back in the old days – maybe 40 years ago – neuroscientists thought the brain was fixed, not fluid, and the older you got, the more senile you became.

Not true! (They were also wrong about eating fat making you fat, but I’ll save that for another time.) Your brain has more plasticity than a can of Play-Doh. With luck, and grace, and effort, you can keep it juiced and joyful and learning new things right till the end.

It’s not only possible but also fun!

Here are two brain boosters to help you keep your mind active, your memories sharp and your synapses sparking joy:

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OR TODAY | December 2017

BE YOUR OWN FRED ASTAIRE

It’s well established that your brain thrives on exercise. Physical activity – from cleaning house to climbing walls – increases blood flow to the brain. And within the brain, it stimulates the release of chemicals that make us think better, feel better and even be better at certain tasks, like remembering the point of that story about the guy in yoga class with the apricotcolored poodle.

While all exercise is good for the brain, new research published in Frontiers in Human Neuroscience recently set my toes a-tapping.

Dancing, it turns out, is one of the best exercises you can do for the aging brain.

Repetitive endurance training

(such as cycling and walking) also ranks high when it comes to an antiaging effect on your hippocampus – the region that controls memory, learning and balance – but dancing beats the competition. And here’s the twist: It works best if you’re constantly changing your dance routines and genres. The seniors who showed the biggest boost to their brains were switching between jazz, square, Latin American and line dancing.

“Steps, arm patterns, formations, speed and rhythms were changing every second week to keep them in a constant learning process,” said Dr. Kathryn Rehfield, the lead author in the study. “The most challenging aspect for them was to recall the routines under the pressure of time and without any cues from the instructor.”

Yes! That level of challenge could make me cry, but that’s what the brain likes. And why it wants you to play strategy games such as chess, do word puzzles, read books or take classes that make you think, think, think.

WWW.ORTODAY.COM

COMBINE MENTAL AND PHYSICAL EXERCISE

Another way to strengthen brainpower is to do some brain exercises while the body is in motion.

Excuse me?

“Any movement is good during mental tasks,” writes Lawrence Biscontini, an advisory board member for the International Council on Active Aging, in IDEA Fitness Journal.

“It does not have to be intense.”

So while doing sudoku, sitting still, is good for you, your brain’s neuroplasticity – its remarkable ability to change and adapt – is even more stimulated when you pair it with simple moves such as seated marching or alternating heel raises.

Biscontini has come up with a series of brain-training exercises, including this one: “While your body is in motion, say your favorite color aloud. Spell it forward then backward. How many letters does the word have? Does your telephone number contain that number? If it does, then say the section of your phone number that contains that number. Repeat the numerical answer backwards. If not, then repeat a section of your phone number forward and then backward.”

“Coupling brain games with appropriate movements,” says Biscontini, “is one of the waves of the future for helping to change not that we age, but how we age.”

Yes! And that makes all the difference. If you forget why, start tapping your toes and go back to paragraph five.

No More

Wheel obstructions

– Marilynn Preston is the author of Energy Express, America’s longest-running healthy lifestyle column. Her new book “All Is Well: The Art {and Science} of Personal Well-Being” is available now on Amazon and elsewhere. Visit Creators Publishing at creators.com/books/ all-is-well to learn more. For more on personal well-being, visit www.MarilynnPreston.com.

WWW.ORTODAY.COM

December 2017 | OR TODAY

49

OUT OF THE OR HEALTH

EXERCISE, LIFESTYLE HABITS CAN PREVENT 1 OF 3 BREAST CANCER CASES

B

risk walking or other daily physical activity is one key step to lower the risk of breast cancer for women of all ages, yet far too few Americans recognize this link, according to experts at the American Institute for Cancer Research (AICR).

AICR’s latest awareness survey conducted earlier this year found that only four of 10 Americans (39 percent) know that physical activity plays a role in cancer risk.

Along with breast cancer, physical activity protects against colon and endometrial cancers.

“Our recent report, summarizing the research from around the world, showed that there is strong evidence that regular vigorous physical activity reduces the risk of breast cancer in both pre- and post-menopausal women,” said Nigel Brockton, PhD, AICR’s Director of Research. “Women of all ages can lower their risk of breast 50 OR TODAY | December 2017

cancer by adding vigorous physical activity to their daily lives.

That’s a simple message that can have a powerful impact.”

AICR research estimates that one of every three U.S. breast cancer cases annually could be prevented by limiting alcohol intake, increasing activity and being a healthy weight.

VIGOROUS ACTIVITY NOW LOWERS RISK FOR YOUNGER WOMEN

Diet, nutrition, physical activity and breast cancer showed, for the first time, that vigorous exercise such as cycling or running

helps prevent pre-menopausal breast cancer. Evidence also confirmed vigorous activity lowers risk for post-menopausal breast cancers, the most common form of this cancer.

For vigorous exercise, premenopausal women who were the most active had a 17 percent lower risk and post-menopausal women had a 10 percent lower risk of developing breast cancer compared to those who were the least active.

Both vigorous and moderate activities linked to lower risk of post-menopausal breast cancer.

Total moderate activity, such as walking and gardening, linked to a 13 percent lower risk when comparing the most versus least active women.

WWW.ORTODAY.COM

WEIGHT AND LIMITING ALCOHOL

The report showed other key steps that women can take to lower their risk, including: • Get to – and stay – a healthy weight: Being overweight or obese is one of the strongest factors to increase risk of post-menopausal breast cancer. Excess fat can promote chronic inflammation, and increase blood levels of insulin and related hormones that can spur the growth of cancer cells. Along with breast cancer, overweight and obesity increases risk of 10 other cancers, including ovarian, endometrial and colorectal.

• Work to maintain a healthy weight or not gain any more: Greater adult weight gain also linked to increased risk of this type of breast cancer.

• Limit alcohol: Drinking even one glass of wine or other alcoholic drink a day on a regular basis linked to higher risk of breast cancers.

Risk continues to rise with higher amounts. Alcohol or ethanol is a carcinogen, which could damage DNA and increase levels of hormones that fuel cancer. AICR recommends that for women who do drink, limit the amount to one glass or less a day.

Notes Alice Bender, MS, RDN, AICR’s Director of Nutrition Programs: “Our report focused on lowering risk for breast cancer, but research also shows that for everyone, including cancer survivors, taking these same lifestyle steps can help lower risk for chronic diseases like heart disease and type 2 diabetes.”

For new moms, the report found that breastfeeding reduces the risk of both post- and premenopausal breast cancers.

WWW.ORTODAY.COM

CONTINUE YOUR EDUCATION

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OUT OF THE OR NUTRITION

REPORT FINDS WHOLE GRAINS LOWER COLORECTAL CANCER RISK

E

ating whole grains daily, such as brown rice or whole-wheat bread, reduces colorectal cancer risk, with the more you eat the lower the risk, finds a new report by the American Institute for Cancer Research (AICR) and the World Cancer Research Fund (WCRF). This is the first time AICR/WCRF research links whole grains independently to lower cancer risk.

The report “Diet, Nutrition, Physical Activity and Colorectal Cancer” also found that hot dogs, bacon and other processed meats consumed regularly increase the risk of this cancer. There was strong evidence that physical activity protects against colon cancer.

“Colorectal cancer is one of the most common cancers, yet this report demonstrates there is a lot people can do to dramatically lower their risk,” said Edward L. Giovannucci, MD, ScD, lead author of the report and professor

54

OR TODAY | December 2017

of nutrition and epidemiology at the Harvard TH Chan School of Public Health. “The findings from this comprehensive report are robust and clear: Diet and lifestyle have a major role in colorectal cancer.”

The new report evaluated the scientific research worldwide on how diet, weight and physical activity affect colorectal cancer risk. The report analyzed 99 studies, including data on 29 million people, of whom over a quarter of a million were diagnosed with colorectal cancer.

Other factors found to increase colorectal cancer include: • Eating high amounts of red meat (above 500 grams cooked weight a week), such as beef or pork • Being overweight or obese • Consuming two or more daily alcoholic drinks (30 grams of alcohol), such as wine or beer LOWERING RISK WITH FIBER, ACTIVITY AND GRAINS

The report concluded that eating approximately three servings (90 grams) of whole grains daily reduces the risk of colorectal cancer by 17 percent.

It adds to previous evidence showing that foods containing fiber decreases the risk of this cancer.

For physical activity, people who are more physically active have a lower risk of colon cancer compared to those who do very little physical activity.

WWW.ORTODAY.COM

Here, the decreased risk was apparent for colon and not rectal cancer.

In the U.S., colorectal cancer is the third most common cancer among both men and women, with an estimated 371 cases diagnosed each day.

AICR estimates that 47 percent of U.S. colorectal cancer cases could be prevented each year through healthy lifestyle changes.

Notes Giovannucci: “Many of the ways to help prevent colorectal cancer are important for overall health. Factors such as maintaining a lean body weight, proper exercise, limiting red and processed meat and eating more whole grains and fiber would lower risk substantially. Moreover, limiting alcohol to at most two drinks per day and avoidance or cessation of smoking also lower risk.”

FISH, FRUITS AND VEGETABLES

The report found other links between diet and colorectal cancer that were visible but not as clear.

There was limited evidence that risk increases with low intake of both non-starchy vegetables and fruit. A higher risk was observed for intakes of less than 100 grams per day (about a cup) of each.

Links to lowering risk of colorectal cancer was with fish and foods containing vitamin C. Oranges, strawberries and spinach are all foods high in vitamin C. “The research continues to emerge for these factors, but it all points to the power of a plant-based diet,” says Alice Bender, MS, RDN, AICR Director of Nutrition Programs. “Replacing some of your refined grains with whole grains and eating mostly plant foods, such as fruits, vegetables and beans, will give you a diet packed with cancerprotective compounds and help you manage your weight, which is so important to lower risk.”

“When it comes to cancer there are no guarantees, but it’s clear now there are choices you can make and steps you can take to lower your risk of colorectal and other cancers,” says Bender.

WWW.ORTODAY.COM

CONTINUE YOUR EDUCATION CLOROX

ADVICE PRE-OPERA TIVE PROT SPOTLIGHT OCOLSOR TODAY LIVE ON SPOTLIGHT ON PAGE 11 JOBY HYMA ARIC CAMPLING SURGICAL CONFERENCE N PAGE 52 PAGE 10 PAGE 54

TAKE GO NURSES •OD CARE SURGICAL TECHS • NU RSE MANA TAKE GOOD CARE GERS NURSES • SURGICAL TECHS • NURSE MANAGERS

HEALTH

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OUT OF THE OR RECIPE

BY DIANE ROSSEN WORTHINGTON

H

aving written two books on soups, I know my way around a soup pot. I love soups made with any kind of noodles, and rice noodles are the stars in this Vietnamese soup. Pho, pronounced “fuh” (like duh), is a popular noodle soup that many consider to be the national dish of Vietnam.

There are many stories about how pho became a Vietnamese classic dish. Literary accounts suggest that pho originated in the north in Hanoi in the mid-1880s.

Others debate that the French influence can be seen in the beef broth, similar to Pot au Feu. Saigon popularized pho in the late 1950s, stamping their flavor profile on the soup. You can also see the Chinese influence through such Asian ingredients as star anise pods, cilantro and fresh ginger.

“The Pho Cookbook” by Andrea Nguyen ($22, Ten Speed Press) offers the reader a world of pho recipes.

This cozy bowl of comfort comes in all versions. If you are interested in trying out different styles, this book is 56

OR TODAY | December 2017

for you. It also describes in great detail the ingredients, equipment, unusual broth techniques and bowl assembly tips. Nguyen promises that “if you can boil water, you can master Vietnam’s national dish.” There are sections for simple, fast, meatless and old-school stunners.

I developed my pho version when I wanted a onedish meal with some exotic flavor. If you have the broth cooked ahead, it takes little time to put this together and will be a welcome surprise to your family and friends.

The base is a strong beef broth perfumed with star anise, peppercorns and ginger. Look for a good quality beef broth in your local supermarket; or, if you have the time, make it yourself.

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RECIPE

VIETNAMESE BEEF AND NOODLE SOUP

IS A ONE-DISH MEAL Translucent rice noodles float in the bowl topped by thin beef slices and sautéed sweet and crisp shallots. Some cooks add beef meatballs, but sprigs of fresh Thai basil, mint and cilantro always accompany pho. Bean sprouts, chilies and fresh squirts of lime also are added for a burst of flavor.

Some people prefer the hot sauce squirted into the soup, but I like to add a spoonful of hoisin for another layer of Asian flavor. Look for many of these ingredients at an Asian grocery store.

DIRECTIONS

1

I n a medium soup pot combine all of the ingredients for the broth on medium high heat and bring to a boil. Reduce the heat to low, cover and cook for 10 minutes or until the broth is fragrant and infused with the spices.

Strain the broth into a medium soup pot. Reserve.

2

eanwhile, place the rice sticks in a bowl and cover with warm water for M about 20 minutes or until very pliable.

3

hile the broth is simmering and the noodles are softening; heat the oil W in a nonstick skillet on medium high heat. Add the sliced shallots and brown, turning with tongs to evenly brown for about 3 to 4 minutes or until nicely browned. Drain on paper towels and reserve.

4

Have ready 4 large deep soup bowls. Reheat the beef broth on high heat to a boil.

5

ring a large pot of water to a boil on high heat. Drain the noodles. Place B 1/4 of the noodles in a strainer and immerse in the boiling water for about 10 seconds or until tender but still firm. Drain the noodles and place in a soup bowl. Repeat with the remaining noodles in the other bowls.

6

ivide the beef slices among the bowls. Ladle over the boiling broth (the D hot broth will cook the meat). Divide the herbs, bean sprouts, chilies and the shallots among the bowls. Serve immediately with lime wedges, hoisin sauce and large spoons.

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

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VIETNAMESE BEEF AND NOODLE SOUP (PHO BO) Serves: 4 FOR THE BROTH: 8 cups best-quality beef broth 5 whole cloves 4 thin slices peeled ginger 3 star anise pods 1 cinnamon stick 1 teaspoon black peppercorns 1 onion, sliced Salt and pepper FOR THE PHO: 1 package (6 3/4 ounces) dried medium rice sticks 1/4 cup canola oil 8 shallots, peeled and sliced 1/2 pound very thinly sliced eye of the round beef (have your butcher do this for you on the thinnest setting), cut into 2-inch widths or bite size pieces 1 small bunch cilantro leaves 1 small bunch mint leaves 1 small bunch Thai basil leaves (do not substitute other basil for this variety) 1 cup bean sprouts 2 small red chilies, stemmed, seeded and thinly sliced 1 lime quartered Hoisin sauce or hot sauce like Sriracha (for serving)

December 2017 | OR TODAY

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FRUIT SNACKS AND TASTY INGREDIENTS

L

ove your snacks but don’t want the guilt that usually comes with feeding your sweet tooth? Meet Stoneridge Orchards’ organic dried fruits – a wide selection of premium fruits that are carefully picked, hand-selected and dried to all-natural deliciousness.

The fruits (blueberries, strawberries, peaches, cranberries, and Montmorency cherry) are available in individual packs or multifruit variety packs, and now dipped in ultra-smooth rich dark chocolate or creamy Greek yogurt also.

Stoneridge Orchards’ organic dried fruits are available nationally. But, they aren’t just for snacking. The Stoneridge Orchards’ website offers several recipes including this tasty Thanksgiving staple.

60 OR TODAY | December 2017

TURKEY CRANBERRY STUFFING INGREDIENTS 1 cup butter 1 cup chopped white onion 1/3 cup chopped rosemary 1 cup chopped carrots 2 tbsp fresh chopped garlic 2 cups chopped celery 1 8 oz. can chopped water chestnuts 1/2 cup chopped pecans 3 cups chicken broth 1-2 bags of Stoneridge Orchards dried cranberries 2 14 oz. bags of bread cubes

DIRECTIONS 1. Begin creating the base by mixing the butter, onion and rosemary on low heat. When the onions get translucent add in the carrots, garlic, then celery, water chestnuts, pecans and dried cranberries.

2. Transfer the mixture to a larger pot and then add in the chicken broth and heat for about 10 minutes.

3. Add in the bread cubes and mix this up until everything is coated well.

4. Heat this in the oven at 325 degrees for about 30 minutes and serve.

Note: Alternately you can stuff a turkey with the stuffing mixture and cook in the oven at 325 degrees for appropriately 20 minutes per pound of the turkey.

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DEBUNKING THE MYTHS BEHIND THE REAL VS. ARTIFICIAL TREE DEBATE Popular myths are that real trees are bad for the environment, artificial trees make more financial sense and real trees are just a hassle, but read on for some facts that will set the record straight and some thoughts that might turn your head on some of the more subjective sides of the debate.

• If your No. 1 concern is the environment, your No. 1 choice should be a real tree. Growing, using and recycling real Christmas trees is good for the environment. Research shows that when compared on an annual basis, the artificial tree has three times more impacts on climate change and resource depletion than the natural tree. Real Christmas trees are biodegradable and can even be recycled or reused for mulch, and every year the circle of life continues. Artificial trees are petroleumWWW.ORTODAY.COM

based products and most are imported from overseas. Many are thrown away seven to 10 years after they’re purchased, and every year the landfills where they will stay (literally for centuries) get a little bit bigger.

• Still don’t like the idea of cutting down a tree? Remember that just like the Halloween pumpkin you carve with your kids or the fresh-cut flowers you buy for a loved one on special occasions, real Christmas trees are farmer-planted and hand-harvested specifically for people to enjoy. And, for every real Christmas tree harvested, a new tree is planted.

• If it’s your wallet that worries you, keep in mind that it’s no surprise that artificial things frequently cost less than real things. True, not everyone agrees “you get what you pay for,” but there’s a

second economic case to be made for buying a real Christmas tree: Real Christmas trees provide real business for real farmers. Fully 100 percent of real Christmas trees sold in the U.S. are grown in North America.

Ultimately, with all of the myths aside, a real Christmas tree is a choice you can be proud of. Whether you prefer to shop at a neighborhood store, local farm, seasonal lot or even online, there’s a real Christmas tree available for everyone. For more information, visit Facebook.com/ItsChristmasKeepItReal.

– Brandpoint

December 2017 | OR TODAY

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INDEX ALPHABETICAL AAAHC………………………………………………………… 53

Flagship Surgical, LLC……………………………… 16

Microsystems……………………………………………… 38

AIV Inc.……………………………………………………………21

Healthmark Industries Company, Inc.…… 39

Pacific Medical……………………………………………… 6

AORN……………………………………………………………… 9

Innovative Medical Products…………………… BC

Palmero Health Care………………………………… 52

Belimed………………………………………………………… 19

Innovative Research Labs………………………… 49

Paragon Services……………………………………………17

C Change Surgical……………………………………… 15

Key Surgical………………………………………………… 13

Pure Processing……………………………………………… 5

Cincinnati Sub-Zero (CSZ)…………………………… 4

MD Technologies inc.………………………………… 52

Ruhof Corporation…………………………………… 2, 3

Cygnus Medical…………………………………………… 22

Medi-Kid Co.………………………………………………… 59

TBJ Incorporated………………………………………… 29

Encompass Group……………………………………… 19

MedWrench………………………………………………… 58

TIDIShield Transport………………………………… IBC

ANESTHESIA Innovative Research Labs………………………… 49 Paragon Services……………………………………………17

Ruhof Corporation…………………………………… 2, 3 TBJ Incorporated………………………………………… 29 TIDIShield Transport………………………………… IBC

RESPIRATORY Innovative Research Labs………………………… 49

ASSOCIATION AAAHC………………………………………………………… 53 AORN……………………………………………………………… 9

INSTRUMENT STORAGE/TRANSPORT Belimed………………………………………………………… 19 Cygnus Medical…………………………………………… 22 Key Surgical………………………………………………… 13 TIDIShield Transport………………………………… IBC

INDEX CATEGORICAL

CARDIAC PRODUCTS C Change Surgical……………………………………… 15

INVENTORY CONTROL Key Surgical………………………………………………… 13

CARTS/CABINETS Cincinnati Sub-Zero (CSZ)…………………………… 4 Cygnus Medical…………………………………………… 22 Flagship Surgical, LLC……………………………… 16 Healthmark Industries Company, Inc.…… 39 Innovative Research Labs………………………… 49 TBJ Incorporated………………………………………… 29

ONLINE RESOURCE MedWrench………………………………………………… 58

CRITICAL CARE Innovative Research Labs………………………… 49

OR TABLES/BOOMS/ACCESSORIES Innovative Medical Products…………………… BC

DISINFECTANTS Cygnus Medical…………………………………………… 22 Palmero Health Care………………………………… 52 Ruhof Corporation…………………………………… 2, 3

OTHER AIV Inc.……………………………………………………………21

ENDOSCOPY Cygnus Medical…………………………………………… 22 Healthmark Industries Company, Inc.…… 39 Ruhof Corporation…………………………………… 2, 3

MONITORS Pacific Medical……………………………………………… 6

OTHER: CRANIOFACIAL RECOVERY PRODUCTS Medi-Kid Co.………………………………………………… 59 OTHER: PEDIATRICS Medi-Kid Co.………………………………………………… 59

ERGONOMIC SOLUTIONS Pure Processing……………………………………………… 5

PATIENT MONITORING AIV Inc.……………………………………………………………21 Pacific Medical……………………………………………… 6

FALL PREVENTION Encompass Group……………………………………… 19

PATIENT WARMING Encompass Group……………………………………… 19

FLUID MANAGEMENT SOLUTION Flagship Surgical, LLC……………………………… 16

POSITIONING PRODUCTS Cygnus Medical…………………………………………… 22 Innovative Medical Products…………………… BC Medi-Kid Co.………………………………………………… 59

GENERAL AIV Inc.……………………………………………………………21 INFECTION CONTROL Belimed………………………………………………………… 19 Cygnus Medical…………………………………………… 22 Encompass Group……………………………………… 19 Healthmark Industries Company, Inc.…… 39 Palmero Health Care………………………………… 52 Pure Processing……………………………………………… 5 62

OR TODAY | December 2017

REPAIR SERVICES Cygnus Medical…………………………………………… 22 Pacific Medical……………………………………………… 6 REPROCESSING STATIONS Pure Processing……………………………………………… 5 TBJ Incorporated………………………………………… 29

SAFETY Flagship Surgical, LLC……………………………… 16 Healthmark Industries Company, Inc.…… 39 Key Surgical………………………………………………… 13 TIDIShield Transport………………………………… IBC SINKS Pure Processing……………………………………………… 5 TBJ Incorporated………………………………………… 29 STERILIZATION Belimed…………………………………………………………

Cygnus Medical……………………………………………

Healthmark Industries Company, Inc.……

TBJ Incorporated…………………………………………

19 22 39 29

SURGICAL INSTRUMENT/ACCESSORIES C Change Surgical……………………………………… 15 Cygnus Medical…………………………………………… 22 Healthmark Industries Company, Inc.…… 39 Key Surgical………………………………………………… 13 SURGICAL MAT SOLUTIONS Flagship Surgical, LLC……………………………… 16 TELEMETRY AIV Inc.……………………………………………………………21 Pacific Medical……………………………………………… 6 TEMPERATURE MANAGEMENT C Change Surgical……………………………………… 15 Cincinnati Sub-Zero (CSZ)…………………………… 4 Encompass Group……………………………………… 19 TRACKING SYSTEMS Microsystems……………………………………………… 38 WARMERS Belimed………………………………………………………… 19 Cincinnati Sub-Zero (CSZ)…………………………… 4 WASTE MANAGEMENT Flagship Surgical, LLC……………………………… 16 MD Technologies inc.………………………………… 52 TBJ Incorporated………………………………………… 29

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Making Knee Positioning Easier and More Precise. Again.

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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.

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© 2017 IMP