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contents features
50 FILLING THE VOID: RECRUITING AND RETAINING OR NURSES The nursing shortage in the U.S. could get worse before it gets better. Half-amillion seasoned nurses are expected to retire by 2022, according to the Bureau of Labor Statistics. This translates into the need for 1.1 million new nurses to replace those retiring and accommodate an expansion in the delivery of health care services. Statistics like these should make OR nurse hiring and retention a top priority for health care organizations.
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Avante Health Solutions is a cost-saving, one-source medical equipment company. The new and rapidly growing company is a complete medical equipment provider, giving its customers access to new and refurbished capital equipment, installation, service, parts and support.
Join in the conversation as operating room nurses and techs discuss hot topics and emerging trends. The community is also a place to share advice and helpful tips. In this issue, OR professionals tackle gossip and head coverings.
Several reports are forecasting continued growth for the global anesthesia markets. An increase in the number of surgeries being performed along with a decrease in the recovery time after surgery are some of the reasons driving the growth of the market.
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OR Today (Vol. 18, Issue #02) February 2018 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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contents features
PUBLISHER John M. Krieg
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Each month we post the news and photos that caught our eye. Be sure to enter the photo contest this month!
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ART DEPARTMENT Jonathan Riley Karlee Gower Kathryn Keur
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ACCOUNTING Kim Callahan
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Learn about Cookie Sanchez’s career path as a nurse!
Pork chops with apple and dried fruit sauce
SPOTLIGHT ON
RECIPE OF THE MONTH
DIGITAL SERVICES Travis Saylor Cindy Galindo Jena Mattison
CIRCULATION
INDUSTRY INSIGHTS 10 News & Notes 18 Company Showcase 20 OR Today Webinars 22 ASCA 24 Be Prepared 28 AORN
IN THE OR
30 Suite Talk 33 Market Analysis 34 Product Focus 40 CE Article
OUT OF THE OR 56 Fitness 58 Health 60 Nutrition 62 Recipe 64 Pinboard
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INDUSTRY INSIGHTS
news & notes
New Study Examines Pulsed Xenon UV Xenex Disinfection Services’ LightStrike Germ-Zapping Robots have been proven to quickly destroy the germs and bacteria in ORs that can cause infections using pulsed xenon ultraviolet (PX-UV) light. Hundreds of hospitals use LightStrike robots to disinfect their ORs after the day’s procedures are complete and two hospitals have published peer-reviewed studies showing 46 to 100 percent reductions in their SSI rates when the LightStrike robot was used to disinfect ORs after terminal cleaning. In an attempt to reduce contamination in the OR between surgeries, researchers evaluated the LightStrike robot in the OR and found that it can effectively disinfect high touch surfaces in just two minutes. According to the new study “Evaluation of a pulsed xenon ultraviolet disinfection system to decrease bacterial contamination in operating rooms” Haddad et al.;
published in BMC Infectious Diseases, “this short cycle time may make between-case cleaning [with PX-UV] in the OR a viable option and something hospitals should consider operationalizing within their protocol.” The study found that a 2-minute cycle of intense pulsed xenon ultraviolet (PX-UV) light disinfection eliminated 72 percent more pathogens on high-touch surface areas in the OR than manual cleaning alone. The authors noted that the short room turnover time is feasible, even for a busy OR, and could potentially reduce pathogen transmission to patients and reduce SSI rates. Twenty-three peer-reviewed articles have been published about the LightStrike robot’s effectiveness, including nine crediting the intense pulsed xenon UV technology for contributing to a facility’s reduction in HAI rates. •
STERIS Helps St. Michael’s Hospital Surgical Schedule Stay On Track When St. Michael’s Hospital began a major building and renovation project, its Medical Device Reprocessing Department (MDRD) had to move out of its longtime home in the basement so its space could be modernized to meet Canadian Standards Association requirements and improve workflow. The hospital needed an innovative solution that would allow the MDRD to continue to function 24/7 and provide clean and sterile medical devices and equipment to all areas of the hospital from the operating rooms to the catheterization lab. With more than 30,000 surgical cases a year, St. Michael’s knew even the slightest interruption in service or sterility standards was unacceptable. The solution ultimately came from St. Michael’s sterile processing partner, STERIS Corporation, in the form of a mobile MDRD on wheels. The mobile MDRD is a 53-foot expandable unit set up in a courtyard adjacent to the hospi-
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tal. The unit is approximately 1,000 square feet of MDRD space when fully deployed. It is outfitted to accommodate up to eight staff and the hospital’s daily volume of surgical instrument cleaning and sterilization using state-of-the-art washers and sterilizers. “We have very high expectations and stringent requirements for sterile processing and infection control, and we were both familiar and comfortable with STERIS’s mobile sterilization solutions unit,” said Catherine Hogan, director of perioperative services at St. Michael’s. Once construction was completed, Hogan’s department moved into a new space, complete with state-of-the-art STERIS sterile processing equipment. The department, and the hospital, didn’t miss a beat and continued full operations of the surgical department as a result of using the mobile MDRD. •
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news & notes
EvergreenHealth Implements UV Technology to Enhance Hospital Safety As part of its ongoing commitment to patient safety, EvergreenHealth has partnered with Clorox Healthcare to bring advanced ultraviolet light disinfecting technology to the health system’s existing patient safety and infection-fighting protocols. The Clorox Healthcare Optimum-UV Enlight System will complement EvergreenHealth’s comprehensive infection control plan, which combines manual surface disinfection with the new pathogenkilling UV technology. The new disinfecting system uses state-of-the-art ultraviolet (UV-C) light technology to eliminate dangerous pathogens, such as Methicillin-Resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile), which can survive on surfaces in the health care environment for extended periods and pose a threat to patients, staff and visitors. Following standard cleaning and disinfecting procedures, the mobile UV-C unit is brought in to provide another layer of protection and ensure even hard-to-reach areas in hospital rooms that may be difficult to clean by hand are thoroughly treated. The system works by emitting UV-C light, the highest-energy form of ultraviolet
light, in a full 360 degrees, killing microorganisms by inactivating their DNA which renders them harmless and unable to replicate. After standard manual cleaning and disinfecting procedures, the lightweight device can disinfect areas within an 8-foot radius in just five minutes. In a typical patient room, the system is deployed for three five-minute cycles, once on each side of the bed and once in the patient bathroom. A similar protocol is used for operating rooms at the end of each day. The system also tracks device usage across rooms, locations and operators, and provides automated, real-time diagnostic data and reporting. Research from the University of Pennsylvania showed that using the Optimum-UV Enlight System in combination with manual surface disinfection, helped reduce C. difficile infection rates among high-risk patients by 25 percent over a 12-month period – and without impacting room turn-over times. The results were achieved in hematology/oncology units that had persistently high C. difficile infection rates, despite high compliance with other evidence-based prevention measures. •
Medline Acquires Centurion Medical Products Medline has completed the acquisition of Centurion Medical Products. In addition to being a market leader in minor procedure trays, Centurion manufactures an innovative portfolio of vascular insertion trays and best-in-class securement dressings that complement the Medline ERASE BSI solution. Centurion will continue to operate as a subsidiary of Medline. Centurion’s best known products include SorbaView SHIELD Securement Systems, SorbaView Dressings, Com-
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pass pressure monitoring technologies, ECO-EMEBAG and CVC Zone Bundles. Centurion kits and dressings are manufactured in five facilities in Michigan, North Carolina, Pennsylvania, Arizona and Mexico. Medline is the largest privately held manufacturer and distributor of highquality medical supplies and solutions in the U.S. with annual sales of more than $10 billion and more than 16,000 employees worldwide. “The addition of Centurion to
the Medline family gives us a complete product offering in the vascular access market and brings more depth to our infection prevention solutions for customers,” said Jim Pigott, group division president at Medline. “As health care’s focus increasingly moves towards prevention, we are ensuring we can meet and anticipate the needs of providers in this area.” •
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INDUSTRY INSIGHTS
news & notes
Getinge and Verb Surgical Inc. Announce Partnership Getinge, a global leader in medical technology, and Verb Surgical Inc, a Silicon Valley based startup developing a next generation surgical platform, have announced a new strategic partnership. In this partnership, Getinge and Verb Surgical will combine their know-how and specific strengths to offer what promises to be a game-changing platform for the next generation of surgery. The Getinge & Verb solution of Surgery 4.0, or Digital Surgery, will include robotics, advanced visualization, advanced instrumentation, operating room integration, connectivity and data analytics/ AI. As a result, Getinge enters the robotic surgery field in partnership with Verb. Going forward, Getinge and Verb will together explore and develop a next generation surgical platform by combining Getinge’s deep knowledge in instrument reprocessing, OR equipment and IT solutions with Verb’s expertise in robotics, advanced instrumentation, enhanced visualization, connectivity, and data analytics/AI. “We have said since our inception that Verb will be an open platform company, and we want to work with the best technologies and partners in the world in revolutionizing the operating room and surgical care,” said Scott Huennekens, President and CEO of Verb Surgical. “We are extremely excited to announce this partnership with Getinge, which brings world-class complementary technologies and a global footprint as we move to democratize surgery worldwide.” •
HFAP Quality Report Identifies Top Accreditation Deficiencies According to the newly released HFAP Quality Report 2017, many health care facilities struggle to comply with emergency management, physical environment and life safety code standards when undergoing an accreditation survey. These top areas of deficiencies underscore the importance of collaboration between clinical, administrative and engineering teams to ensure facilities are monitored and maintained to meet current regulations. The HFAP Quality Report provides key insights garnered from HFAP surveyors’ ratings of compliance collected during 2016 onsite surveys of acute care hospitals, critical access hospitals (CAH), laboratories and ambulatory surgery centers (ASC). The report highlights the frequency of deficiencies associated with the health care physical environment in an effort to emphasize the significant role engineering teams and facilities managers play in creating safe health care environments. “HFAP’s Quality Report is designed to not only list the top deficiencies identified during surveys, but also provide common examples from surveyors’ experiences, as well as tips for how to improve and achieve compliance,” said Meg Gravesmill, CEO of AAHHS, which manages HFAP. “We use the data collected from all surveys to create a comprehensive, educational resource to support customized quality improvement across all the types of facilities HFAP accredits.” • To download the HFAP Quality Report 2017 or for more information on the HFAP accreditation process, visit www.hfap.org.
InstruSafe Launches New Trays InstruSafe Instrument Protection Trays by Summit Medical, an Innovia Medical Company, announced the release of two new trays to the market. The two new trays – an instrument tray and an endoscopic adapter tray – have each been designed in collaboration with and validated specifically for the
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Senhance Surgical Robotic System instrumentation. “We are excited to expand our product offering to include trays that hold the new Senhance Surgical Robotic System instrumentation,” said Summit Medical’s Marcus Super. “This is yet another example of how
we continue to collaborate with innovative leaders in the surgical robotic system space and continue to build our reputation as industry leaders for instrument protection.” • For information, visit www.instrusafe.com.
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Innovative Medical Products Offers Softgoods Products Innovative Medical Products Inc. has developed a wide range of softgoods products that help improve patient safety, speed surgical recovery and assist OR staff in achieving better patient outcomes. IMP’s softgoods family of positioning solutions include: Humbles LapWrap: easy-to-use positioning pad not only secures patients’ arms during surgery but also allows access for IV tubes and leads for anesthesia. Universal SteriBump: guarantees sterility, helping to reduce health care-associated infections at the surgical site. SuperBump: sterile, weighted, single-use solution is designed to be positioned on top of the OR table drapes at any location on the operating table during a total knee procedure. Hip Abduction Pillows: with a unique convoluted foam design, this solution assures greater patient comfort and easier nursing care after hip surgery. Sterile Protective Pads: for use with all positioning devices. Gel-Infused Memory Pads: provide for better patient protection during surgical procedures including robotic surgery; the pads come in a variety of shapes and sizes tailored to fit specific IMP patient positioning systems. IMP’s “Value Added Commitment” (VAC): the sterile protective pads are a component of IMP’s Value Added Commitment program where participants who use IMP positioners and softgoods exclusively, in accordance with IMP protocol, can receive value-added benefits and services for the life of their IMP positioners. •
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INDUSTRY INSIGHTS
news & notes
Diversey’s MoonBeam3 Disinfection System Wins Award Diversey has received the 2017 Association for the Healthcare Environment (AHE) Innovation Award for its MoonBeam3 Disinfection System, a device that uses powerful ultraviolet (UVC) technology to kill pathogens on hightouch surfaces. The annual innovation award recognizes products, processes and technology advancements that help improve patient outcomes. Designed to be used in conjunction with manual cleaning and disinfection, the MoonBeam3 system’s three adjustable arms allow users to target the UVC dose, taking disinfection to the next level. The arms each generate a broad umbrella (a 7 foot by 11 foot area) of intense, 254-nanometer wavelength UVC light to quickly kill pathogens. The system has been thirdparty tested and demonstrates three-to five-log reductions in harmful pathogens such as MRSA, VRE, MDR Gram negative bacteria, and norovirus in as little as 3 minutes and C. diff spores in as little as 10 minutes. Weighing less than 40 pounds, the MoonBeam3 system is ultra-portable, enabling environmental services professionals
to disinfect even tight spaces like patient restrooms. It also incorporates a number of safety features, including infrared motion sensors, proximity sensors and a physical accelerometer. The bright yellow cover acts as a safety cone to alert staff and visitors that the device is in use, and as a remote control that starts the device from outside of the room and automatically stops the cycle if entry or motion is detected. •
RepScrubs Signs Agreement with Premier RepScrubs has signed an agreement with Premier, a health care improvement company with one of the nation’s largest health care group purchasing organizations, to provide more hospitals with one-time-use, recyclable surgical scrubs for the thousands of surgical equipment sales representatives who visit operating rooms every day. Under the agreement, a direct sourcing subsidiary of Premier Inc., S2S Global, will begin manufacturing an exclusive line of RepScrubs, which will be offered to Premier’s alliance of hospitals and health systems. “Surgical sales representatives provide a valuable service and are essential business partners within the health care spectrum, but the ‘street scrubs’ they often wear throughout the day while traveling from hospital to hospital may carry deadly pathogens that can pose a danger to both patients and the public,” said Jeff Feuer, president and CEO
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of RepScrubs. The RepScrubs system offers hospitals a unique way of improving hospital security, infection prevention initiatives and adherence to industry guidelines. It reduces costs while enabling hospitals to better control and manage vendor access. Hospitals install a RepScrubs ScrubPort, which vends a complete recyclable surgical outfit each time a surgical sales rep enters a member facility. The RepScrubs software and reporting allow hospital staff to monitor and manage vendors’ access to ORs and clinical staff areas while shifting the cost of that vendor’s attire back to the vendor. RepScrubs enables the hospital to ensure every rep entering an operating room is wearing clean scrubs dispensed on-site, and is properly documented as adhering to sterile protocol and industry guidelines, giving administrators a new tool in fighting hospital acquired infections (HAIs). •
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SunTech Medical Achieves ISO 13485 with MDSAP Certification Clinical grade blood pressure device specialist SunTech Medical has successfully upgraded its ISO 13485 certification to include the Medical Device Single Audit Program (MDSAP) standard. ISO 13485 with MDSAP confirms that SunTech meets all regulatory requirements in the U.S., Canada, Brazil, Japan and Australia for medical device design and manufacturing. Introduced in 2014, MDSAP certification requires that the recipient pass an extensive auditing process to prove its existing quality management system meets the requirements set forth by governing bodies in the U.S., Canada, Brazil, Japan and Australia for the design and manufacture of medical devices. “We are proud to be one of the few companies who has successfully completed the MDSAP program,” SunTech Medical President Rob Sweitzer said. “The certification assures our customers that our manufacturing practices are among the best in the world.” •
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Robotics-assisted Knee Replacement Completed Smith & Nephew, a global medical technology business, recently announced completion of the world’s first robotics-assisted bicruciate retaining total knee replacement procedures. The NAVIO robotics-assisted surgical system aids in implanting the Journey II XR (bi-cruciate retaining total knee system) which is one of the only total knee designs allowing retention of the ACL, and is designed to improve patient satisfaction. With this launch, NAVIO now offers both partial and total knee options that include the first and only robotics-assisted bicruciate retaining knee procedure, commercially available. Doctors Vivek Neginhal, David Rovinsky and David Fabi recently performed the first cases. The NAVIO is a next generation handheld robotics platform designed to aid surgeons with implant alignment, ligament balancing and bone preparation. The small footprint of NAVIO allows for set up and portability. Furthermore, the NAVIO robotics-assisted system does not require a preoperative image, such as a CT scan. This allows patients to receive the benefits of robotics-assistance without the extra steps, costs and radiation often associated with additional preoperative imaging. •
PowerMATE® Special Purpose Relocatable Power Taps • CMS Waiver Compliant • UL-1363A Recognized • Locking IV Pole Mount • Locking Outlet Covers • 15 & 20 Amp Models Everything we manufacture and repair at AIV is done to ISO-13485 standards.
888.656.0755 • aivsales@aiv-inc.com The manufacturers listed are the holders of their respective names and/or trademarks, and are not to be taken as an endorsement or affiliation with AIV, Inc.
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INDUSTRY INSIGHTS
news & notes
Sterigenics International LLC Changes Name Sterigenics International LLC has announced that it has changed its parent company name to Sotera Health LLC. Its three operating companies – Nelson Labs, Nordion and Sterigenics – will continue to maintain their current names. The new parent company name signals a more integrated and holistic customer value proposition as it combines the offerings of three bestin-class companies to better serve customers with a more comprehensive offering of mission-critical services. The name Sotera was inspired by the Greek goddess of safety, Soteria, and reflects the company’s commitment to global health. Sotera Health has 62 facilities in 13 countries and provides lab services, comprehensive sterilization solutions and a reliable global supply of radioisotopes to the medical device, pharmaceutical, tissue and food industries. The company touches the lives of more than 180 million people around the world each year and serves over 6,000 global customers, including 75 percent of the top 100 medical device manufacturers. “Safeguarding Global Health is the cornerstone of our new brand and guides us in what we do each and every day,” said Michael B. Petras Jr., CEO of Sotera Health. “It speaks to the breadth of our business and our ability to partner with our customers across their entire product-development lifecycle.” •
New Study Validates UV Disinfection Technology A new study has been published regarding Tru-D and its deployment at Virginia Commonwealth University Health System (VCU). The study, “Deployment of a touchless ultraviolet light robot for terminal room disinfection: The importance of audit and feedback,” appeared online recently in the American Journal of Infection Control. The study was conducted at VCU. Data was collected during a 25-month period from February 1, 2015-February 28, 2017. During the study, there were 420,394 patient days and 99,184 admissions. In the study, VCU set a goal of 90 percent utilization of the Tru-D robots for high-risk rooms. Through Tru-D’s real-time usage-tracking features and by educating environmental services (ES) on the importance of patient safety, VCU achieved 100 percent utilization. The study stated, “The deployment was performed with structured education, audit and feedback, and resulted in a multidisciplinary practice change that maximized the UV disinfection capture rate from 20 percent to 100 percent.” From February 2015 until January 2017, two Tru-D robots were used, and in mid-January 2017, two additional robots were purchased. “This study is a testament to the process of implementing a successful UV disinfection program and maximizing utilization,” said Alice Brewer, director of clinical affairs for tru-d smartuvc. “vcu was ultimately able to achieve 100 percent utilization on the highest risk rooms due to Tru-D’s data portal along with our strategic approach to Program Management.” Validated by more than a dozen independent studies including the only randomized clinical trial on UV disinfection, Tru-D’s technology has been proven by science to provide a safer patient environment. • To learn more or to read independent studies, visit Tru-D.com.
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Combining leading brands to be your One Source for capital equipment, parts, and service. Avante Health Solutions provides a single source solution for all your capital equipment needs from one trusted partner. We are a one-stop, brand-agnostic supplier of high-quality, new and refurbished equipment at prices that stretch your dollar. And with best-in-class service, parts, and repair, the perfect health solution is one click away.
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Company Showcase vante Health Solutions is a cost-saving, one-source medical equipment company emerging at a time when medical facility budgets are pinched and consolidation is quickly changing the health care landscape.
By relying on Avante as a single point of contact for their health care equipment needs, medical facilities can focus on what they do best: delivering quality care to their patients.
The new and rapidly growing company is a complete medical equipment provider, giving its customers access to new and refurbished capital equipment, installation, service, parts and support. Through organic growth and targeted acquisitions, Avante has amassed a breadth of services that compete as a cost-effective alternative to major equipment manufacturers. Over the past few years, Avante has brought together experienced equipment providers across a range of medical equipment specialties, including DRE Medical Group, Integrated Rental Services, Global Medical Imaging, Pacific Medical, Oncology Services International and Transtate Equipment Company. Moving into 2018, each company will become a division under the Avante name, allowing them to work more closely to offer customers a unified purchasing and service experience. “The new name brings our family of companies together under a common theme and message,” Avante
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Avante Health Solutions President and Chief Operating Officer Steve Inacker
Health Solutions President and Chief Operating Officer Steve Inacker said. “At Avante, we are dedicated to helping our customers stay ahead of the curve in a challenging health care cost environment.” The company’s forward-thinking strategy upholds simplicity, convenience, affordability, trust and innovation as core values.
One Convenient Source Avante is leveraging the expertise and capabilities of its companies to deliver a one-source health care equipment solution to facilities across the U.S. In addition to new and refurbished equipment sales, Avante offers support throughout the life cycle of today’s medical equipment market – from sourcing and installation to repairs, service and refurbishing.
Beyond changing the way medical facilities purchase and maintain their capital equipment, Avante is also striving to offer its customers a true value in today’s medical equipment marketplace. “Our primary goal is to continue to be recognized by our customers and the market as a high-quality, low-cost alternative to OEMs for the product and service solutions that we offer,” Inacker said.
Brand Agnostic Approach Avante utilizes an unbiased, brand indifferent strategy that allows the company to outfit its customers with the best equipment for their unique needs. This includes either factory new or professionally refurbished equipment options from leading manufacturers.
Comprehensive Selection & Service The conglomeration of the Avante family of companies provides customers with unprecedented access to a complete range of equipment options for any facility type, size or specialty. WWW.ORTODAY.COM
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company showcase Avante
Avante is currently comprised of six companies, which will soon be adopting the Avante name in order to further unify the brand: DRE Medical Group, Inc., Louisville, Kentucky | Avante Medical Surgical Integrated Rental Services, Inc., Louisville, Kentucky | Avante Rental Services Global Medical Imaging, Charlotte, North Carolina | Avante Ultrasound Pacific Medical, San Clemente, California | Avante Patient Monitoring Oncology Services International Inc., Montebello, New York | Avante Oncology Services Transtate Equipment Company, Concord, North Carolina | Avante Diagnostic Imaging
Avante Medical Surgical DRE Medical has been a provider of operating room equipment for more than 30 years, offering new and refurbished lines of anesthesia machines, surgical tables, surgical lighting, procedure chairs, defibrillators, respiratory ventilators, exam and diagnostic equipment and more.
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critical rental component to the Avante service offering. The company will provide JCAHO compliant medical equipment rentals to hospitals, clinics, surgery centers, doctor’s offices and other medical facilities.
Avante Ultrasound Founded in 2002 as a “brand indifferent” ultrasound solutions provider, GMI has grown into an authority on cost-effective diagnostic imaging solutions in both the private practice and hospital markets.
Avante Patient Monitoring Pacific Medical is a proven source of outstanding customer service and patient monitor, patient module, telemetry transmitter, fetal monitor, transducer, infusion pump and syringe pump sourcing. The dual ISO-certified company boasts the largest patient monitoring inventory in the industry.
Avante Oncology Services As a partner to hospitals and cancer centers since 1985, Oncology Services International Inc. (OSI) is the leading alternative to OEM service for linear accelerators used in radiation therapy. In addition to being a refurbished equipment provider, OSI also boasts the largest selection of LINAC parts in the U.S.
Avante Diagnostic Imaging For nearly 20 years, Transtate has provided a range of high-quality cath lab, CT scanners,and nuclear camera solutions. Its hyper-focused approach has fueled company growth, allowing Transtate to construct a full-service staging facility that houses thousands of replacement parts and a multi-speciality team of experienced engineers offering onsite repair services.
Forward Thinking Avante’s belief is that in today’s environment, doing more with less requires a progressive strategy and a new way of thinking: that better health care starts with seeing a better way forward. Avante strives to be a better partner, budget alternative and total solution. Uniting the Avante family of companies will bring together the best-of-the-best in the industry and allow the group to provide comprehensive quality care to its customers. Avante is focused on growing within its current markets, as well as expanding into new and complementary markets.
For more information, visit https://avantehs.com. FEBRUARY 2018 | OR TODAY |
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INDUSTRY INSIGHTS
news & notes webinar
Webinar Includes Block Scheduling Tips Staff report he recent OR Today webinar “OR Utilization Guidelines” by Rachel LeMahieu, MSN, RNFA, CNOR, director of surgical services, cath labs and specials at Henderson Hospital in Nevada, was a hit with perioperative professionals.
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She discussed enhancing OR use with modified block scheduling techniques, policy revision for block scheduling, capturing surgeon buy-in for block optimization and using resources for sustaining change in block allocation and utilization. LeMahieu received her BSN from the University of Wisconsin, Madison and her MSN at Gonzaga University in Spokane, Washington. She is responsible for the clinical, financial and administrative functions of the operating room, pre-admit testing center, recovery room, pre-operative area, anesthesia, lithotripsy, sterile processing department, cath/specials lab and endoscopy. She has 17 years of experience in the operating room ranging from circulator, scrub, RNFA, educator, charge nurse, manager and director. Her latest project was the opening of Henderson Hospital Outpatient Surgery Department in the innovative medical community of Union Village. Almost 200 people registered for the webinar and it received positive reviews in a post-webinar survey with a rating of 4.1 on a 5-point scale with 5 being the best possible score. “Fantastic presentation, very impressive approach for block utiliza-
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tion,” shared L. Ru, manager. “With some webinars, you really do not learn a lot. With this one, I did! All organizations struggle with similar issues so it is great to learn from others who have encountered and conquered these issues already. It was nice to have the policies and letter examples as resources along with the content,” said J. Richards, director of perioperative services.
services business manager. “Great webinar. I loved the fact that copies of policies as well as letters to the physicians were provided and shared. It was very helpful to know the calculation of block utilization as well. The tier system seems fair and reasonable,” shared T. Symonds, OR business manager. The webinar series also received praise. “OR Today webinars pro“ This webinar was helpful in vide current, up-to-date useful content and tools in a succinct understanding how other method. The take-aways are worth the brief time spent,” facilities are managing block wrote S. Bisol, principal, periop Leaders Consulting. policies and enforcement to “Practical and real world strategies for common OR drive case volumes.” challenges ... you can’t miss it,” said T. Tscherne, regional – J. Peterson director of surgical services and trauma. “OR Today’s webinar “Excellent data documentation to presentations are timely, and spot on validate implementation of plan of acto the important topics facing today’s tion to increase OR utilization guideOR’s managers and directors,” wrote lines. Excellent presentation,” said D. G. Harmon, director of perioperative Myers, independent consultant. nursing services. “It was a great webinar. I enjoyed “OR Today has awesome webinars hearing about ways doctors could – I can always find one that pertains to enhance their communication in block my area of work,” wrote S. White, RN, scheduling. Talking to them in person CNOR. and also writing letters seems very effective. Also liked the color coding For information about the OR Today block schedule,” said V. Mallery, RN. webinar series, including recordings of “This webinar was helpful in under- previous webinars and a schedule of standing how other facilities are manupcoming sessions, visit ORToday.com aging block policies and enforcement and click on the “Webinars” tab. to drive case volumes. Thank you for the insight,” said J. Peterson, surgical WWW.ORTODAY.COM
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INDUSTRY INSIGHTS asca
Standing Strong, ASCs Head into 2018 by WILLIAM PRENTICE
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ith 2017 quickly receding in our rearview mirror, it’s time to take stock of the ways that health care policy decisions made in 2017 will affect individual ASCs and the ASC community in 2018. It is also a good time to look at what new developments and recurring policy proposals we can expect to see on the horizon for ASCs in 2018. At the national level, two key issues that ASCA spent considerable time addressing last year moved in a positive direction. First, as ASCA requested, the Centers for Medicare & Medicaid Services (CMS) delayed the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS). That decision means that the survey is not mandatory for ASCs in 2018. Although the ASC community supports the idea of conducting OAS CAHPS surveys, ASCA has been encouraging CMS to keep the survey voluntary until an electronic option is available and the survey can be shortened. Adoption of these two recommendations would significantly reduce the cost burden these surveys pose to ASCs and make the surveys much easier for ASC patients to complete. Second, again as ASCA requested, CMS removed Total Knee Arthroplasty (TKA) from Medicare’s inpatient-only (IPO) list beginning in
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2018. This decision means that this procedure now has a reimbursement rate for the hospital outpatient department (HOPD) setting. While fee-forservice Medicare TKA cases will not be reimbursed in the ASC setting in 2018, the removal of TKA from the IPO list is an important step toward Medicare coverage of this procedure in ASCs in the future. ASCA has been at the forefront of the advocacy efforts aimed at removing TKA and other joint replacement surgeries from Medicare’s inpatient-only list and led efforts to make multiple presentations before CMS medical officers on the safety and efficacy of outpatient joint replacements. Meanwhile, support in the medical community for the idea of moving more of these procedures into the ASC setting continues to grow. In 2018, ASCA will remain front and center in the efforts still needed to define and implement meaningful measures in Medicare’s ASC quality reporting program, fight burdensome regulatory requirements that have no ties to improved patient care and address the growing gap between Medicare’s ASC and hospital outpatient department (HOPD) payments. Also in 2018, ASCA will continue to work to provide essential resources to ASCs to help make regulatory compliance easier and, simultaneously, save ASCs both time and money. Although not all are available at this time, ASCA’s plans for 2018 include
expanded ASC infection preventionist training opportunities, a comprehensive handbook that will help ASCs comply with the newest life safety code guidelines and a user-friendly online regulatory compliance tracking and training tool with lots of other bells and whistles attached. At the state level in 2017, ASCA supported efforts that • Stopped ASC provider tax bills in Louisiana and Oregon • Successfully amended a provider tax bill in Nevada to establish ASCs as their own health care provider class so that any taxes imposed on ASCs in the state would have to be voted in by ASCs themselves • Successfully amended a Louisiana regulation to allow for 23hour stays; previously, patients in the state could not remain in an ASC past midnight • Successfully stopped a bill in Nevada that would have granted the state medical board the ability to determine which procedures ASCs could perform • Defeated legislation in Illinois that would have tied workers’ compensation rates to Medicare rates • Reformed the certificate of need (CON) process in Massachusetts through regulations that remove a moratorium on ASC development. WWW.ORTODAY.COM
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When it comes to state health policy, ASCs need to remain vigilant because it is easy to underestimate how quickly a decision made in one state can be replicated in states across the country. Issues we expect to re-emerge this year include provider taxes, staff certification requirements and workers’ compensation and Medicaid fee schedule reductions. As always, to be as effective as possible, we need as many ASCs as possible to be involved. If you work in an ASC that is not already an ASCA member, please sign up today by contacting ASCA Assistant Director, Membership, Mykal Cox at 703-636-0623 or mcox@ascassociation.org. If you are not sure if your ASC is an ASCA member, please
get in touch with Mykal. If you want to network with ASC professionals from across the country and learn the latest about ASC regulatory compliance, market trends and management topics of every kind, sign up now for ASCA’s annual meeting in Boston, Massachusetts, April 11-14. Registration is open now at www.ascassociation.org/asca2018. Early registration rates close February 24, so act fast to get the best deal. ASC hospital and joint venture partners who want to learn more about the business of managing ASCs are also invited. William Prentice is the Chief Executive Officer of the Ambulatory Surgery Center Association.
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INDUSTRY INSIGHTS
be prepared
Are You Prepared for the Increased Acuity of Your Patients? Making a Case for Preoperative Testing in the Outpatient Surgical Setting by DAVID TAYLOR MSN, RN, CNOR, CVOR he surgical environment is fast paced and oftentimes unpredictable. In fact, patient acuities are higher and the care they need is more complex. Yet the ambulatory market is constantly evolving. Health care professionals with a creative mindset actively seek out opportunities to improve operational and clinical efficiencies. They also look to help their organization function more effectively to improve its market position. Rather than waiting to adjust to industry changes these professionals make changes to their business model quickly to create market trends or keep up with innovations. Their fast action has allowed them to surpass hospital-based surgical programs and secure a greater percentage of the market share.
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Much has changed in the field of surgery in the past century. Long gone are the days of admitting patients a week before surgery and keeping them hospitalized for weeks postoperatively. Today’s physicians can diagnose, treat and manage disease processes along with chronic conditions once thought to be intractable. Surgical procedures are
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becoming safer and more effective than ever in part because of advanced surgical techniques, new devices and innovative technology. Surgeons are not alone. Much of the advancement in surgery can be attributed to advances in anesthetic and nursing care. The knowledge gained from technological innovation and advancements in medicine have been tremendous assets in an ever-changing profession that is rapidly moving forward. As a result of medical advancements ambulatory surgery centers (ASC) are experiencing tremendous growth in recent years. The first freestanding ASC was established in Phoenix, Arizona and opened on February 12, 1970. Wallace Reed, MD, and John Ford, MD, wanted to provide convenient, timely and cost-effective surgical services to patients in their community, thus avoiding the more impersonal and less efficient setting of hospitals.1 Five surgeons performed cases at the center on opening day, and four of those patients required general anesthesia.2 From 1996 to 2006 the rate of visits to freestanding ASCs increased approximately 300 percent with over 57 million procedures performed. In comparison, the rate of visits to hospital-based surgery centers remained largely unchanged during the same period.3 Patients who were once believed to be unsuitable for ambulatory surgery are now considered to be appropriate candidates as
medical advancements improved and the use and selection of anesthesia provided in the ambulatory setting rapidly evolved. Surgical procedures once believed to be unsuitable in the outpatient setting are now routinely performed regardless of the patient’s age. Those same procedures are now routinely performed earlier in the day so patients can be discharged in the late afternoon or early evening hours.4 As the types of procedures performed in the outpatient setting continue to expand, it is inevitable that patients with higher comorbidity will influence how surgical care is provided. As the outpatient market sees greater volume as a result of their efficient processes and lower costs, accurate patient selection and appropriate scheduling will be essential to ensure safe patient outcomes. Instituting optimal planning is essential to prevent negative outcomes, sentinel events and increased cancelations and/or delays on the day of surgery (DOS). Managing the aforementioned will be key to future success in this market. In a 2012 report, the American Hospital Association explored the question, “Are Medicare patients getting sicker?” They found that approximately four out of five seniors affected by chronic conditions with two-thirds having at least two or more chronic conditions. It is expected that these WWW.ORTODAY.COM
numbers will continue to grow as the Medicare population grows.5 This trend isn’t just in the Medicare population. Dr. Edward J. Merrens of Dartmouth Medical School and director of Dartmouth-Hitchcock Medical Center’s Hospital Medicine Program describes hospitalized patients as sicker on average than a decade ago and illnesses that once required hospitalization are now being treated on an outpatient basis. He goes on to say, “We are caring for inpatients today who might not have survived to this point years ago. So clinic physicians’ twice-a-day rounds to care for their hospitalized patients are no longer enough.”6 With the growing prevalence of chronic conditions it is imperative that health care organizations, particularly those in the ambulatory market, make clinical and operational improvements to their patient preparation and selection process to ensure successful outcomes and maximize the benefits of risk assessment that identify patient factors, which can significantly increase the risk for complications.7 Proactively managing the surgical patient preoperatively will help to reduce the cost of care, initiate postoperative teaching for the more complicated patients, minimize cancelation rates and/or delays and improve the patient experience enjoyed by the outpatient world. Patients who present with significant medical histories and multiple co-morbidities require additional planning prior to the actual surgical encounter. One way to minimize these challenges is to create or strengthen pre-surgical testing (PST) services. Patient preparation, scheduling and pre-registration DOS discharge planning and post-surgical recovery are all interconnected. Accurate scheduling is essential to optimize planning and pre-surgical testing which lends itself to a collaborative approach between anesthesia and the presurgical nursing teams. By systematically completing the necessary level of PST services days or weeks before the surgical encounter, an ACS can help minimize complications and ensure appropriate consultation prior to surgery. Enhancing patient preparedness and creating a more friendly and thorough experience, as well as build confidence in the patients served, will allow the ambulatory market to continue with its high patient satisfaction ratings. From a business perWWW.ORTODAY.COM
spective, organizations who better prepare patients for surgery can avoid costly delays, reduce or eliminate unexpected cancelations and mitigate negative outcomes, which could unnecessarily require greater length of stay (LOS) or transfer of care. Enhancing the patient preparedness process not only creates a more friendly and inviting experience for the patient, it provides a thorough look into their health history which can help the ambulatory market avoid unnecessary hospital readmissions and postsurgical procedures. The PST team could be made up of registered nurses, support technicians such as laboratory and radiology personnel as well as an anesthesia provider. Each component plays a role in the preparation and care of that patient.
INDUSTRY INSIGHTS
be prepared
outcomes. In addition to categorizing patients, a well-designed PST team could incorporate a standardized scheduling process that incorporates pre-operative order sets used for all procedures to ensure adequate information is obtained for a safe patient experience. Lastly, the PST process could develop a set of pre-anesthesia guidelines for laboratory testing. By creating and using set criteria or protocols the process can identify what level of pre-surgical testing is needed for each patient type. With respect to the level categories, not all procedure Establishing new criteria to identify the types listed will be performed in an ASC level of pre-surgical testing needed for setting. However, it is important to point each patient could be established out that a growing number of procedures utilizing evidence-based practices not are being approved for this setting. This is only in an ASC setting but in a particularly important because, according hospital-based program as well. to 2010 data, 48.3 million surgical and nonsurgical proceEstablishing new criteria to identify dures are being performed in hospital and the level of pre-surgical testing needed for ASC settings.10 each patient could be established utilizStandardizing a new system for safer ing evidence-based practices not only in surgery will require a commitment not an ASC setting but in a hospital-based only from the administrators of the program as well. For example, creating organization but also from surgeons who categories identifying patients undergoing schedule procedures and an agreement such procedures as a joint replacement, among anesthesia providers to form a spine, vascular, cardiac, abdominal or a consensus on a protocol-driven approach craniotomy may need one level of screento patient preparation.9 Each party will ing. In addition, identifying patients that need to champion the process changes in have significant medical histories and coorder to avoid status quo and to improve morbidities such as a cardiac history, liver negative outcomes. disease, chronic respiratory history, diabetes Pre-surgical testing is only part of the mellitus, or blood disorders;8 the patient equation. Baby boomers are reaching the would be required to schedule an appoint- age of Medicare eligibility at the rate of ment with the PST team. Patients not 10,000 a day. This group is exhibiting a scheduled for one of the aforementioned growing prevalence of chronic conditions procedures and those that do not present and risk factors for those conditions.5 As with one of the co-morbidities would only this generation ages, their health care usage require a telephone health screen with a will increase, which will drive procedure PST registered nurse.9 This collaborative volumes for many specialties. The ambulaapproach helps grow volumes by eliminat- tory market needs to continuously evaluate ing the unknowns and safeguards surgical the increasing need for more nursing care, FEBRUARY 2018 | OR TODAY |
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INDUSTRY INSIGHTS
be prepared as required in this setting, to care for these 2009; 28(11): 1-25 http://www.ncbi. info/doctor/general-anaesthesia accessed patients.11 Along with the appropriate level nlm.nih.gov/pubmed/19294964 accessed 12/4/2017 of health care providers, it will be neces12/4/2017 9. Ellis, S., Young, D., Peters, J. A., ‘Hybrid’ sary to have the appropriate supplies and 4. Lichtor, J. l., General information on Pre-Op Assessment Model Increases OR equipment on hand and readily available Ambulatory Anesthesia, Stanford MediEfficiency at Nebraska Hospital. Anesin the event of an emergency. This will cine Ether, http://ether.stanford.edu/asc/ thesiology News, March 2013, VOL39 help prevent unforeseen transfers of care. general_info_ambulatory_anesthesia.html NO3 Posted March 22, 2003 http://www. The ambulatory market is expected to accessed 12/13/2017. anesthesiologynews.com/ViewArticle.as continue growing. Surgical procedures that 5. Are Medicare Patients Getting Sicker?, px?d=Policy%2B%26%2BManagement were once hospital based will merge and American Hospital Association Trend &d_id=3&i=March+2013&i_id=937&a_ eventually move to the outpatient market. Watch, December 2012, www.aha. id=22716 accessed 12/4/2015 In order for ACSs to be successful and org/.../tw/12dec-tw-ptacuity.pdf accessed 10. Hall, M. J., et al. Ambulatory Surgery Data grow their reputation, volume and abilities 12/5/2017 from Hospitals and Ambulatory Surgery to deliver quality care on a day-to-day basis 6. Merrens, EJ, Meeting 24/7demands, Centers: United States, 2010. National they will need to address the total care of Dartmouth Medicine http://dartmed. Health Statistics Reports NO 102, Februthe patient population. dartmouth.edu/summer05/html/grand_ ary 28, 2017 CHANGESaccessed NEEDED With the Affordable PROOF Care ActAPPROVED (ACA) rounds.php 12/3/2017 11. Why a Column on Ambulatory Best and the movement toCLIENT a value-based pay7. Gupta, A., Gupta, N., Setting up and Practices?, AORN Journal May 2014, VOL SIGN–OFF: ment model, the focus on quality has never functioning of a preanaesthetic clinic. 99, NO 5. CONFIRM THAT THE FOLLOWING ARE54(6) CORRECT been higher. ASCs offer highPLEASE patient satisIndian Journal of Anesthesia http:// 12. Pre-Procedural Preparation Toolkit 2007 PHONE NUMBER WEBSITE ADDRESS NSW SPELLING GRAMMAR faction rates and low infection ratesLOGO while www.ncbi.nlm.nih.gov/pmc/articles/ Health http://www1.health.nsw. offering consumers a convenient and costPMC3016569/ accessed 12/4/2017 gov.au/pds/ActivePDSDocuments/ effective alternative. With a push to move 8. General Anesthesia, Patient trusted mediGL2007_018.pdf accessed 12/13/2017 TRIM 4.5” more inpatient volumes to the ambulatory cal information and support http://patient. setting it will be important to manage patient needs preoperatively because the PST process optimizes the patient’s condition prior to their planned procedure.12 The vigilant management of patient risk factors will allow the ambulatory market to leverage resources efficiently to improve performance as well as outcomes in the operating room and postoperatively. This will give ASCs an advantage over hospitalbased surgical programs. It will also ensure that the last patient of the day has the same opportunities for success, recovery and discharge home as the first.
PROO
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WWW.ORTODAY.COM
TRIM 4.5”
1. http://www.ascaconnect.org/ASCA/ AboutUs/WhatisanASC/History/ accessed 12/3/2017 2. Rechtoris, M., 50 things to know about the ambulatory surgery market., July 22, 2015 http://www.beckersasc.com/ asc-turnarounds-ideas-to-improveperformance/50-things-to-know-aboutthe-ambulatory-surgery-center-industry. html accessed 12/6/2017 3. Cullen K. A., Hall, M. J., Golosinskiy, A. Ambulatory surgery in the United States, 2006. National Health State Report
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INDUSTRY INSIGHTS
aorn news & notes
5 Clinical and Leadership Skills to Build in 2018 Staff report
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ith the rapid pace of technologies being adopted in the OR and the wealth of new evidence reshaping perioperative practices, nurses can’t afford to fall behind. However, it takes the right mix of clinical and leadership skills to be competent in the latest clinical practices and be able to apply that clinical excellence in a team setting, explains AORN CEO and Executive Director Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN. “The pride a professional registered nurse feels when fully prepared to provide the safest patient care possible is immeasurable,” Groah says. She says today’s successful perioperative nurses have a clear need, as well as a moral responsibility, to strategic lifelong learning that will keep them relevant for their patients, their colleagues and the profession. As nurses look to the clinical and leadership skills they need to build in 2018, Groah shares five patient safety topics with relevant and timely application for the perioperative setting: • Infection Prevention – such as applying the latest evidence in preventing surgical site infection and ensuring safe practices for each step in instrument processing.
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• Team Communication – to consider evidence-based approaches for communication throughout a patient’s continuum of surgical care, such as briefings, surgical pauses, and hand-overs; and team communication training approaches such as simulation. • Medication Safety – to address evidence-based approaches that protect patients and personnel such as safe injection practices, safe disposal of hazardous waste, and safe approaches to protect patients from medication errors. • Product Evaluation – to provide valuable input from the perioperative perspective regarding products used in care delivery and to also understand the value of the products including quality outcomes and costs. • Patient Experience – to consider evidence-based approaches to prevent adverse events such as venous thromboembolism and to consider the best approaches for value-based patient care. Groah acknowledges that finding time for building these various nursing skills becomes the challenge, however, attending one conference for multiple education needs can be the solution.
Learning at AORN’s 2018 Annual Conference For perioperative nurses able to attend
AORN’s 2018 Global Surgical Conference & Expo in New Orleans, March 24-27, planning ahead can be valuable to schedule time for education sessions that will cover these and other hot topics, such as designing patient experience, preventing peri-prosthetic infections, understanding the basics of forensic investigation that apply to the OR setting, and new strategies for laser safety compliance. For those nurses taking on more business and administrative work, AORN’s Executive Leadership Summit held during the conference on March 25-27 will address many of these needed educational areas for both experienced and novice leaders. For example, topics to be addressed at the summit include predictive analytics, change strategies, disruptive innovation and team competence.
“ The pride a professional registered nurse feels when fully prepared to provide the safest patient care possible is immeasurable.” WWW.ORTODAY.COM
INDUSTRY INSIGHTS
aorn
Attendees who visit the conference and expo will find opportunities to learn about emerging OR technologies and network with product representatives to better understand products that may soon be coming to their ORs for evaluation and use. On the exhibit floor, opportunities for simulation education will support nurses in building clinical skills including fire evacuation, positioning and emergency preparedness.
Making Connections For Groah, sharing knowledge is just as important as gaining knowledge. That’s why she encourages conference attendees to take time to expand their network of colleagues to learn about and share best practices and other safety trends. “Take time to explore research posters to seek out solutions to challenges you face and gain perspectives on care strategies from nurses practicing in different
practice settings,” Groah says. To support global collaboration among perioperative nursing, AORN’s annual meeting will include a Global Summit with speakers from Europe, Australia, North America and Asia speaking together in a series of panel discussions. These panel speakers will address several topics, including implementing and sustaining enhanced recovery after surgery [ERAS] programs, managing drug abuse in health care workers, operating room design, patient safety, preparing the patient for surgery and comparing policies on managing incivility. Groah also encourages attendees to take the knowledge gained at the conference back to their practice settings to support colleagues in providing perioperative patients with the best care experiences possible. Nurses unable to attend the conference can build their skills with new
education and evidence-based practices AORN is sharing in 2018. Here are a few to take advantage of: • 2018 edition of Guidelines for Perioperative Practice with implementation resources • Nurse Executive Leadership Seminars • Certification support with AORN’s Prep for CNOR Live “When we take the Nightingale pledge to ‘maintain and elevate the standard of my profession,’ a critical part of keeping this oath is making sure we are competent in all areas that may impact our patients’ care,” Groah explains. To explore the education schedule and learn about other opportunities that can serve to expand clinical and leadership skills at AORN’s 2018 Global Surgical Conference & Expo, visit www.aorn.org/ surgicalexpo.
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IN THE OR suite talk
Suite Talk
Conversations from OR Nation’s Listserv THESE POSTS ARE FROM OR NATION’S LISTSERV JOIN THE CONVERSATION, VISIT WWW.THEORNATION.COM
Q Q
GOSSIP IN THE OR
When the OR is busy everyone gets along fine, but when the OR is slow, people are quick to start gossiping. Any suggestions on how to stop the gossip mill?
A: This is such a true statement and if anyone has
been successful handling this issue please share.
A: Have a downtime list of duties to assign like: • Cleaning out dusty bins • Checking outdates • Restocking rooms to PAR levels • Updating preference cards • Putting away supplies tucked/stashed in areas
where they don’t belong • Techs cross train to sterile processing/or float to help out • RNs can help make post op calls for SDS • RNs and techs cross train in GI and • Create Unit Base Councils (UBC) to work on projects to help the future of your OR’s function These are just a few ideas off the top of my head. I hope it planted the seeds for a few ideas.
BOUFFANT OR SURGICAL SKULLCAP?
AORN and the CDC recommend hair be covered to promote patient safety and decrease the risk of surgical site infection. AORN does not recommend one type of head covering over another. Do you prefer a bouffant or surgical skullcap?
A: Here is a snapshot of the AORN Guidelines for Head Coverings. Of interest, there is conflicting
evidence about head covering but this should guide our practice: “researchers concluded that the ears should be covered by surgical head covers during surgery.” The skullcap will not adequately do this.
ecommendation III R Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair. The benefit of covering the head, ears, and hair is the reduction of the patient’s exposure to potentially pathogenic microorganisms from the perioperative team member’s head, hair, ears, and facial hair. • III.a. A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn. [2: Moderate Evidence] A literature review by McHugh et al identified several conflicting studies related to the need for a surgical head covering. The authors concluded there was little evidence to suggest that covering the hair reduces SSI rates; however, they acknowledged that surgical team members wearing head coverings
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IN THE OR suite talk decreased bacterial contamination of the surgical field. • Owers et al conducted a nonexperimental study in which 20 OR team members had their foreheads, eyebrows, and ears cultured. The researchers found there was significantly more bacteria isolated from the ears than from the foreheads and eyebrows of the surgical team members. The researchers concluded that the ears should be covered by surgical head covers during surgery. ° III.a.1. Personnel wearing scrub attire should not remove the surgical head covering when leaving the perioperative area. [4: Benefits Balanced with Harms] The purpose of the head covering is to contain hair and minimize microbial dispersal. When the head cov-
ering is removed, hair and microbes may be shed onto scrub attire. Head coverings commonly used in the perioperative setting (eg, bouffant caps) are worn for hair and skin containment and are not considered PPE. The Occupational Safety and Health Administration requires that PPE not permit blood, body fluids, or other potentially infectious materials to pass through or reach the employee’s clothing, skin, eyes, or other mucous membranes under normal conditions of use
when exiting the building decreases the possibility of contamination with microorganisms present in the external environment. ° III.a.3. Used single-use head coverings should be removed at the end of the shift or when contaminated and should be discarded in a designated receptacle. [4: Benefits Balanced with Harms] ° III.a.4. Reusable head coverings should be laundered in a health careaccredited laundry facility after each daily use and when contaminated (see Recommendation II.b). [2: Moderate Evidence] Head coverings are part of the scrub attire.
° III.a.2. Personnel should remove surgical head coverings whenever they change into street clothes and go outside of the building. [4: Benefits Balanced with Harms] Removing surgical head coverings
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Global Anesthesia Markets Continue Upward Swing Staff report everal reports are forecasting continued growth for global anesthesia markets.
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Mordor Intelligence predicts growth in the global anesthesia drug market. “The global anesthesia drugs market has been estimated at $11.54 billion in 2016 and is projected to reach $14.11 billion by 2021, at a CAGR of 3.4 percent during the forecast period from 2016 to 2021,” according to Mordor Intelligence. Mordor Intelligence includes a bump in the number of surgeries as one reason for its positive market outlook. “Increasing number of surgeries, development of new sedative and anesthetic drugs, reduction in the cost of newly invented drugs and decrease in the recovery time after surgery are some of the reasons driving the growth of the market,” according to Mordor Intelligence. However, it is not all good news for the anesthesia market. “Risk of side effects of anesthesia drugs, lack of skilled anesthetists to administer the drugs and risk of adverse reactions of anesthesia drugs are some of the major constraints hindering the WWW.ORTODAY.COM
market growth,” Mordor Intelligence adds. Mordor Intelligence also forecasts that the global anesthesia devices market will reach $13.50 billion by 2021, at a CAGR of 11.64 percent during the forecast period from 2016 to 2021. “This market has witnessed an excellent growth in the recent times. This growth is expected to increase accordingly in the near future as well,” Mordor Intelligence reports. “Continuous growth in this market can be attributed to the rapid adoption of anesthesia information management systems (AIMS), which have been implemented in an effort to move the industry away from the paper-based record keeping systems to more efficient electronic solutions,” the report adds. “The establishment of several government-supported national statistical databases is driving this market as well. The demand is also rapidly increasing with the growing safety awareness and technology enhancements in anesthesia machines.” A PRNewswire report expects even more growth, especially in the United States market. “United States anesthesia market is expected to be more than $4 billion
by 2022. This growth is driven by increasing incidence of cardiovascular cases, growing old age population and rising number of urgent surgeries in United States,” according to the report. “Private as well as public health insurers also help to boost this market as they consider anesthetic products in their reimbursement policy.” General anesthesia is expected to add to the overall anesthesia drug market. “The U.S. general anesthesia drugs market is poised to reach $2.0 billion by 2020 from $ 1.6 billion in 2015, at a CAGR of 3.8 percent from 2015 to 2020,” MarketsandMarkets reports. “Factors such as rapid rise in aging population, rising prevalence of cardiovascular and respiratory systemrelated diseases, and rising number of emergency surgeries are driving the growth of the U.S. general anesthesia drugs market. However, side effects associated with ketamine usage (such as elevation in blood pressure and heart rate, amnesia, respiratory depression, and hallucinations), regulatory issues, and lower compliance rates in comparison with other anesthetic drugs are likely to restrain the growth of this market.”
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product focus
BD
Pyxis Anesthesia ES system Take a simpler, safer and more secure approach to patient-centric care in OR and procedural areas. Pyxis Anesthesia ES system offers clinical workflows centering on the patient to help increase medication safety and anesthesia workflow efficiency. By controlling access to medication, it promotes compliance with regulatory requirements. Built on the Pyxis ES platform, it helps standardize medication management. •
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Draeger
Perseus A500 Anesthesia Workstation A highly configurable anesthesia workstation, the Perseus A500 can be easily tailored to meet your needs. Its generous, well-lit workspace can be used to keep supplies organized and within reach. Its compact, heated breathing system is designed to reduce condensation build-up and facilitate fast gas exchange rates. And to support continuity of care between the ICU and OR, the Perseus A500 offers Airway Pressure Release Ventilation (APRV). •
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product focus
GE Healthcare Aisys CS²
Modular and upgradeable, with Aisys CS² you’re planning for the future while protecting your investment. Electronic agent control allows you to capture set agent concentrations and precisely measures agent usage. The 15-inch touchscreen ventilator display and ecoFLOW option displays oxygen flow alongside pre-set targets while calculating anesthetic agent cost and usage in real-time. Clinicians can use this to adjust oxygen flow to help avoid unnecessarily high fresh gas flow rates. •
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Infinium
ADS II Anesthesia Systems The Infinium ADS II anesthesia systems offer pure simplicity in patient ventilation and anesthetic delivery. The ADSII features highly accurate tidal volumes with 15 mL capability and a 12-inch touchscreen. It also features electronic flowmeters (Air, N20, O2). It is autoclavable. It has ventilation modes of VCV, PCV, SIMV+PS. It features highly mobile space saving design with a retractable writing table, battery backup and more. •
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Mindray
A7 Anesthesia Workstation with Optimizer The new A7 Anesthesia Workstation takes the well-received A-Series to a higher level. The feature-rich A7 combines advanced ventilation with electronic fresh gas technology and Optimizer functionality to provide effective care across a wide range of patients. Electronic fresh gas control ensures precise, accurate and responsive flow dynamics while the Optimizer provides low flow and inhalation agent management tools to support hospital initiatives to improve clinical outcomes and reduce costs. Real time agent usage calculation, advanced ventilation modes, integrated suction, auxiliary common gas outlet, and a convenient pull out table, provide the necessary tools for today’s clinical and cost-saving requirements. With built-in HL7 connectivity to AIMS and EMR systems and an industry-leading threeyear warranty, the A7 functions as a truly comprehensive workstation that saves time, space and cost. •
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AORN BOOTH #431
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continuing education
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continuing education
CE476
A Lurking Danger
A ‘Bundle’ of Safety Measures Available to Fight Central Line Infections by May Mei-Sheng Riley, MSN, MPH, RN, ACNP, CCRN, CIC
silent killer lurks in every U.S. hospital: central lineassociated bloodstream infection. CLABSIs affect an estimated 80,000 patients in ICUs each year, and about 250,000 hospitalwide CLABSI are assessed.1 It is difficult to measure the mortality rate independently related to CLABSI because patient deaths are affected by multiple comorbidities. Three national data resources in the U.S. were used to estimate the annual number of deaths associated with healthcareassociated infections to be 98,987. About one in three of these HAIs were due to CLABSIs. Therefore, the case fatality rate was about 12.3%.2 CLABSIs are usually serious infections (e.g., sepsis) that lengthen hospital stay, inflate medical cost, and increase the risk of mortality.2 The good news is that CLABSIs are preventable, and nurses are empowered to reduce these troubling numbers.3
A
This module focuses on potentially deadly central venous catheter-associated bloodstream infections. Patients with a CLABSI stay in the hospital about WWW.ORTODAY.COM
12 days longer than patients without a CLABSI.2 The average CLABSI case cost ranges from $16,550 to $49,650, and CLABSI is associated with about 24,000 patient deaths each year.2 Simulations have shown, with 95% confidence, that CLABSIs are the costliest HAIs.3 Given this data, efforts to reduce the rate of CLABSIs are vital to improving healthcare quality and patient safety. The Institute for Healthcare Improvement recommends five key measures based on best-practice guidelines to fight CLABSI:4 • Hand hygiene • Maximal barrier precautions on insertion of the central venous catheter (CVC) • Chlorhexidine skin antisepsis • Optimal catheter site selection; subclavian vein is the preferred site in adults for non-tunneled catheters • Daily review of line necessity, with prompt removal of unnecessary lines Together, this group of evidence-based interventions is called the “central-line bundle.”4 The nurse’s understanding of CLABSI and evidence-based bundle practice can improve patient outcomes significantly.
OnCourse Learning guarantees this educational activity is free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See page 47 to learn how to earn CE credit for this module.
Goal and objectives The goal of this continuing education module is to inform nurses of the severity and causes of central line-associated bloodstream infections, and describe the central-line bundle, a group of evidence-based interventions. After studying the information presented here, you will be able to: • Describe the severity of CLABSIs • Explain the causes and risk factors of CLABSIs • Describe the five components of the central-line bundle
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continuing education A CVC is a catheter inserted into the great vessels in patients who require frequent or continuous injections of medications, fluids, or nutritional support.5 It is an intravascular infusion device used for infusion, withdrawal of blood, or hemodynamic monitoring whose tip terminates at or close to the heart or in one of the great vessels: the aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian vein, external iliac veins, common iliac veins, and femoral veins; and, in neonates, the umbilical artery and umbilical vein.5 CVCs are crucial to medicine, particularly in intensive care, and during major surgery and resuscitation because they provide secure vascular access and reliable hemodynamic measurement. However, central lines can cause complications, such as local infections at the insertion site. Central lines also can cause systemic infections, such as CLABSI; septic thrombophlebitis; endocarditis; and metastatic infection, which includes lung abscess, brain abscess, osteomyelitis, endophthalmitis, or septic arthritis. CLABSI is the most common of these infection-related complications. Clinicians should understand the difference between clinical and surveillance definitions of CLABSI. The clinical definition is physician driven and based on clinical signs and symptoms of BSI or sepsis, the blood culture laboratory results, and the presence of a CVC. The surveillance definition of CLABSI is more specific and less subjective, and it relies on positive blood culture results and the presence of a CVC. The CLABSI definition in this module, developed by the Centers for Disease Control and Prevention (CDC) and the National Healthcare Safety Network (NHSN), has been adopted by most healthcare facilities to generate facility-specific CLABSI rates. This definition lists essential criteria for surveillance of
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CLABSI and succinctly describes the methodology that should be used in CLABSI surveillance systems conducted by healthcare facilities. According to the CDC/NHSN, CLABSI is a laboratory-confirmed BSI, such as bacteremia/fungemia, in a patient with a CVC when no other infection source with the same microorganism is found. If a patient develops a BSI within the period beginning two calendar days after insertion of a CVC and ending two calendar days after its removal, the BSI is said to be associated with the CVC.5 If more than two calendar days pass between CVC removal and the onset of infection, convincing evidence must exist before the infection can be classified as related to the central line.5 Two criteria must be met before a BSI is classified as CLABSI: The patient must have both a CVC and a laboratory-confirmed BSI. The signs, symptoms, and blood culture laboratory results must not be related to an infection at another site. If the same organism is found at a site other than the bloodstream, it is a secondary BSI rather than a primary BSI. For example, if both blood and wound culture results have shown Pseudomonas aeruginosa, the BSI is secondary because the microorganism may have migrated from the infected wound into the bloodstream.5
Surveillance CLABSI Definition by CDC/NHSN Using the CDC/NHSN surveillance definitions, a laboratory-confirmed BSI requires that one of the following three criteria be met:5 Criterion 1: The patient has a recognized pathogen identified from one or more blood specimens by a culture or nonculture-based microbiological testing method that is performed for purposes of clinical diagnosis or treatment AND the pathogen is not related to an infection at another site. Criterion 2: The patient has at least
ONE of the following signs or symptoms: fever (greater than 100.4 F [38 C]), chills, or hypotension, AND the signs, symptoms, and positive laboratory results are not related to an infection at another site. AND A common skin contaminant — e.g., diphtheroids (Corynebacterium spp. not C. diphtheriae), Bacillus spp. (not B. anthracis), Propionibacterium spp., coagulase-negative staphylococci (including S. epidermidis), viridans group streptococci, Aerococcus spp., or Micrococcus spp. — is identified in two or more blood specimens drawn on separate occasions, by a culture or nonculture-based microbiological testing method that is performed for purposes of clinical diagnosis or treatment, occurring within one calendar day of each other with the same skin contaminant found in both results. Criterion 3: A patient younger than 1 year has at least one of the following signs or symptoms: fever (greater than 100.4 F [38 C], core); hypothermia (less than 96.8 F [36 C], core); apnea or bradycardia; AND the signs, symptoms, and positive laboratory results are not related to an infection at another site AND A common skin contaminant — e.g., diphtheroids (Corynebacterium spp. not C. diphtheriae), Bacillus (not B. anthracis), Propionibacterium spp., coagulasenegative staphylococci (including S. epidermidis), viridans group streptococci, Aerococcus spp., or Micrococcus spp. — is identified by a culture or nonculturebased microbiological testing method that is performed for purposes of clinical diagnosis or treatment in two or more blood cultures drawn on separate occasions occurring within one calendar day of each other with the same skin contaminant found in both results. A new criterion was added to the CDC/NHSN CLABSI module: mucosal barrier injury laboratory-confirmed BSI. This criterion is for patients with allogeneic hematopoietic stem cell transplant within a year or for paWWW.ORTODAY.COM
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tients with neutropenia, defined as at least two separate days with values of absolute neutrophil count or total white blood cell count less than 500 cells/mm on or within three calendar days before the date the positive blood culture was collected.3 The criterion also defines specifically the pathogens found in the blood culture.5 The CLABSI criteria do not include catheter tip culture or treatment with antibiotics; therapeutic options are clinical decisions made by healthcare providers. Blood cultures collected through CVCs can have a higher chance of contamination than blood specimens drawn through peripheral venipuncture.5 Therefore, cultures ideally should be collected through venipuncture from two to four blood draws from separate sites. However, this may be difficult in patients with very poor peripheral venous access. Hospital administrators should work to ensure best practices in specimen collection. Blood cultures obtained from any site (through existing intravascular catheters, arterial lines, or venipuncture) must be considered in CLABSI surveillance.
Rating the Risks Despite associated complications, CVCs remain necessary, especially for managing patients in critical condition. Therefore, clinicians must identify and modify the risk factors of CVC-associated infections.1 Multilumen CVCs are indispensable in managing patients requiring several IV medications, laboratory specimens, frequent blood product transfusions, and fluid resuscitations. However, they may be related to a higher rate of CLABSIs and thrombosis than single-lumen CVCs.6 Multilumen catheters are manipulated more often, making colonization and bacterial growth at the tip more common. Hospital policies minimizing the number of lumens may reduce BSI and lower costs.6 WWW.ORTODAY.COM
Femoral CVCs show increased incidence of deep vein thrombosis and catheter colonization. CLABSI due to gram-negative bacteria (e.g., E. coli and Enterobacter spp.) and yeasts is significantly higher in femoral CVC sites because of the proximity of the groin to the genital and perirectal area.7 The subclavian vein has the lowest rate of BSI, followed by the internal jugular vein. The femoral vein has the highest CLABSI rate. Therefore, the subclavian vein is preferred for inserting non-tunneled CVCs (percutaneously inserted into central veins [subclavian, internal jugular, or femoral]).1 In adult patients, the femoral vein should be avoided when placing CVCs under planned and controlled conditions.8 CVCs used to administer dextrosecontaining solutions, total parenteral nutrition or lipids, and blood-product transfusions are associated with increased incidence of BSI. Infusion of total parenteral nutrition and transfusion of blood products are considered a risk factor of CLABSI.1,8 Microorganisms thrive in TPN and high-protein blood products. To protect patients, clinicians must use good antiseptic technique before accessing the CVC. Injection ports should be disinfected with an appropriate antiseptic (e.g., chlorhexidine, povidone iodine, an iodophor or 70% alcohol) before accessing the infusion system.1 Also, only sterile devices should be used to access the injection port.1 Injection ports should be allowed time to dry before the infusion system is accessed. Cap all stopcocks when the injection ports are not in use.1 After infusions of IV solutions that may enhance microbial growth, catheters should be flushed with sterile, preservative-free 0.9% sodium chloride, according to organization policies and procedures and the manufacturer’s recommendations for the type of catheter. According to the CDC guideline, tubing used to
deliver lipid emulsions, blood, or blood products should be replaced within 24 hours of starting the infusion.1 The tubing used to administer propofol infusions should be replaced every six to 12 hours, when the propofol vial is changed, and per the manufacturer’s instruction.1 Replace administration tubing sets not used for blood, blood products, or lipids at intervals no longer than 96 hours.1 ,8 Other risk factors include prolonged hospitalization before CVC insertion, prolonged duration of catheterization, heavy microbial colonization at the insertion site, heavy microbial colonization of the catheter hub, certain patient populations, inexperience of the clinician inserting the CVC, and a low nurse-to-patient ratio. Hospitals should keep nurse-to-patient ratios at least 2:1 in ICUs where nurses manage patients with CVCs and minimize the use of float nurses in the ICU.8 Many groups of patients are vulnerable to BSI, including the older adults, neonates, premature infants, critical patients, patients with severe medical conditions, burn patients, patients with cancer, immunodeficient patients, neutropenia patients, organ transplant patients, immunocompromised patients, and patients on dialysis.1,8
Getting Access To cause a catheter-related infection, microorganisms must access the bloodstream via the outside (extraluminal) or inside (intraluminal) surface of the catheter tube.1,9 After accessing the bloodstream, free-floating bacteria adhere to the catheter surface and form a microcolony. This leads to a biofilm, which allows sustained BSI and hematogenous dissemination (i.e., via the bloodstream). Microorganisms can enter by one of several mechanisms. Skin contaminants, likely aided by capillary action, enter through the skin during catheter insertion or in the days after insertion. Microorganisms can enter the catheter hub and FEBRUARY 2018 | OR TODAY |
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lumen during catheter insertion of a percutaneous guidewire or during manipulation of the catheter. They also can be carried hematogenously to the implanted catheter from a distant local infection, such as pneumonia. The most common route of infection is migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip.1
lin.10 In 1999, for the first time, more than half of all S. aureus infections in ICUs were resistant to oxacillin. When S. aureus resists oxacillin, it is classified as methicillin-resistant S. aureus, which has become endemic in many locations and often causes outbreaks. MRSA contributes significantly to increases in morbidity, mortality, and healthcare costs.1,3,11
Complex Interactions
The central-line bundle correlates with the CDC’s BSI prevention guidelines.1,4 The central-line bundle results in better outcomes than the five measures used individually. Use of the central-line bundle dramatically reduces the incidence of CLABSI, and the reduction is sustainable.12,13 The following is a description of the five key components in more detail.4 Hand hygiene. Good hand hygiene is the cornerstone of infection prevention. Wearing sterile gloves does not eliminate the need for hand hygiene. Cleaning hands before inserting or manipulating a CVC helps prevent contamination of central line sites and resultant BSIs. Hands should be washed with antimicrobial or nonantimicrobial soap and water with adequate rinsing, or cleaned with a waterless, alcohol-based hand sanitizer before donning sterile gloves. The World Health Organization’s key moments to perform hand hygiene are:14 • Before touching a patient • Before clean/aseptic procedures • After body fluid exposure/risk of exposure (and after glove removal) • After touching a patient • After touching patient surroundings
The pathogenesis of the bloodstream comprises complex interactions between the invading microorganism and immune system defenses. When infectious agents spread to the bloodstream, the fever-producing substances secreted by phagocytes will “turn up” the body’s hypothalamic temperature regulator. Vasodilation substances released from the mediators of the inflammatory process in response to overwhelming BSI trigger widespread vasodilation and the reduction of total peripheral resistance. This causes reduced systemic vascular resistance and a decrease in mean arterial pressure. The heart rate is altered because of cardiac compensation. As a result, clinical presentation of BSI includes fever, chills, shaking, tachycardia, and hypotension. The microbial profile of HAIs, including BSI, has changed during the past decades. From 2009 to 2010, the species of bacteria most frequently isolated from blood cultures were, in rank order, coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus faecalis, Candida spp. or not otherwise specified, Klebsiella pneumoniae/oxytoca and Enterococcus faecium.10 (Level A) Coagulase-negative staphylococci and S. aureus were by far the most common, comprising 20.5% and 12.3% of CLABSIs, respectively.10 From 2009 to 2010, 54.6% of blood cultures testing positive for S. aureus were found to be resistant to oxacillin/methicil-
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All Together Now
Maximal barrier precautions on insertion. The clinician inserting the CVC should wear a cap (with all hair tucked under the cap), mask, sterile gown, and sterile gloves. The mouth and nose should be covered tightly by the mask. The patient should be
covered from head to toe with a sterile drape. If a full-size drape is unavailable, use two small drapes to cover the patient. A sterile dressing must be applied to the insertion site before the sterile barriers are removed. Chlorhexidine skin antisepsis. The CDC recommends using >0.5% chlorhexidine gluconate in 70% isopropyl alcohol to disinfect the insertion site.1 To prepare the site, press the applicator against the insertion site and apply the antiseptic solution using a backand-forth friction scrub for at least 30 seconds. Allow the solution to air dry completely, according to the manufacturer’s recommendation before CVC insertion.1 Clinicians should never wipe or blot to dry. According to the CDC, no recommendation can be made for using chlorhexidine-based skin antisepsis on patients younger than 2 months.1 Optimal catheter site selection. In adults, the subclavian vein is preferred for non-tunneled catheters.1 Subclavian venous access has a lower rate of CLABSI than internal jugular or femoral vein access. Subclavian placement may be associated with mechanical complications (e.g., pneumothorax). Patient-specific medical risk factors (e.g., subclavian vein stenosis, coagulopathy, anatomic deformity) should be evaluated carefully when the insertion site is selected.1,4
Daily review of line necessity with prompt removal of unnecessary lines. The risk of CLABSI is related closely to the length of time that a CVC is in place. When physicians and nurses conduct a daily review, unnecessary CVCs are more likely to be removed promptly. A daily review of CVC necessity can be incorporated into multidisciplinary rounds and daily goal reports.4 Use of ultrasound scanner. Ultrasound scanners (designed for guiding vascular access to reduce mechanical complications due to multiple sticks) are not a part of this bundle. WWW.ORTODAY.COM
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Research has shown that there is still an opportunity to improve adherence to the central line insertion practice, and that adherence to central line insertion practices (CLIP) is positively correlated with CLABSI rate reduction.2,15 Every healthcare facility should develop strategies, including leadership involvement, policy development, educational courses, simulation training, and monitoring compliance, to improve adherence to CLIP. Using an electronic health record system can help nurses maximize the benefits of CLABSI-prevention strategies.2
Beyond the Bundle The central-line bundle focuses on the insertion of the catheter rather than later management of the catheter site. The following are recommendations and guidelines for issues that emerge after the catheter is inserted. Guidewires. Replacing a malfunctioning catheter or exchanging a pulmonary artery catheter for a CVC over a guidewire has become common practice. According to the CDC, guidewires should not be used when replacing catheters in patients suspected of having an infection.1 The CDC does not recommend routinely replacing CVCs to reduce BSI.1 If no evidence of CLABSI is present, use a guidewire exchange to replace a malfunctioning non-tunneled catheter as appropriate. Clinicians should wear sterile gloves before handling the new catheter.1 Maximal sterile barrier precautions (including a cap; mask; sterile gown; sterile gloves; and a large, sterile fullbody drape) must be applied during guidewire exchanges for intravascular catheters.1 Pulmonary artery catheters. During insertion of a pulmonary artery catheter, use a sterile sleeve to protect the catheter. Sterile sleeves should be used for all pulmonary artery catheters.1 WWW.ORTODAY.COM
Prophylaxis. Do not routinely administer intranasal or systemic antimicrobial prophylaxis before or during an intravascular catheter insertion to prevent catheter colonization or development of BSI.1 Daily bathing. Consider using a 2% chlorhexidine skin cleansing for daily bathing to reduce CLABSI.1 2,16,17
Catheter and insertion-site care:1,8,16,18 • There is no recommendation regarding the designation of a lumen to use for parenteral nutrition. • Nurses should apply sterile gauze or a sterile, transparent, semipermeable dressing to cover the catheter insertion site. • If the patient is diaphoretic or if the site is bleeding or oozing, apply gauze dressing until this is resolved. • Nurses should immediately replace dressing that is soiled, loosened, or damp; or if moisture, drainage or blood are present under the dressing.18 • Nurses need to perform site care for non-tunneled CVCs in adolescents and adults with a chlorhexidinebased solution and replace gauzesite dressings every two days (seven days for transparent dressings). For some pediatric patients, risk of dislodging the catheter may outweigh benefits associated with dressing changes. Institutional CVC site-care policies should address frequency of dressing changes. • Until the insertion site has healed, nurses should replace dressings used on tunneled or implanted CVC sites no more than once per week. • Do not use topical antibiotic creams or ointments on insertion sites other than for dialysis catheters. Such creams and ointments may promote antimicrobial resistance and fungal infections. • Precautions should be taken to protect the catheter from the introduction of organisms during showering; avoid submerging the catheter in water. • Catheter site dressing regimens:
»» The CDC guidelines for prevention of intravascular catheterrelated infections state that if the CLABSI rate remains higher than the institutional goal despite other strategies (e.g., education and the central-line bundle), use of antiseptic- or antibioticimpregnated short-term CVCs and chlorhexidine-impregnated sponge dressings in patients older than age 2 months is recommended.1 »» However, the Infusion Nursing Society guidelines recommend using chlorhexidine gluconate(CHG-) impregnated dressings over CVCs to reduce BSI risk when the extraluminal route is suspected as the primary BSI source.18 The guidelines also recommend implementing CHGimpregnated dressings even when CLABSI rates are low because these dressings can further reduce CLABSI rates.18 However, when intraluminal sources are the primary infection source, the efficacy of CHG dressings in CVCs beyond 14 days has not been demonstrated.18 Organizational policies, procedures, and protocols should be followed in CVC management to prevent CLABSI. Increased incidence exists of CLABSI in patients with a central line in the jugular site and with tracheostomy versus with a central line in femoral site.8 To keep the central line dressing dry and to protect the insertion site from being contaminated by the respiratory secretion, nurses need to keep the tracheostomy stoma dry and change the tracheostomy holder when the holder becomes moist.
Nurses in Charge Nurses should be trained on the indications of IV catheterization, proper insertion procedure, standardized care of CVCs based on institutional policy, FEBRUARY 2018 | OR TODAY |
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continuing education and the prevention of CLABSI. A hospital’s senior leadership is responsible for ensuring support for the nursing department and the infection prevention and control program that prevents CLABSI. Healthcare providers are responsible for ensuring that optimal CLABSI prevention practice is always followed.8 To implement the central-line bundle and ensure adherence, nurses should be empowered to supervise the insertion procedure. Nurses should have the authority to terminate
procedures if they observe violations of hand hygiene, sterile technique, or evidence-based guidelines for the prevention of intravascular catheterrelated infections. Healthcare providers should be educated to increase their awareness of evidence-based infection prevention practice. Insertion kits, maximum barriers, and 2% chlorhexidine gluconate in 70% isopropyl alcohol applicators should be kept in one location, such as on a single cart so that clinicians can obtain all central-line insertion supplies easily. A CVC insertion checklist should be developed to document adherence, and data should be collected for benchmarking.8,16 Nursing administrators should provide feedback to
the appropriate healthcare providers on unit trends in the incidence and prevalence of CLABSIs and on the strategies to prevent them. More and more patients are discharged with CVCs. Patients and families must be educated before discharge on caring for the catheter and preventing CLABSI. Providing written material can help the patient retain information. The Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America collaborated with the CDC on a compendium of practice recommendations to prevent HAIs, including CLABSIs. Clinicians can use this compendium as a reference.17
Clinical Vignette for CE476 Mr. Smith was admitted to the CCU two weeks ago for cardiomyopathy. A triple-lumen catheter was inserted in his left subclavian vein in the ED, and his condition has since stabilized. The physician had planned to transfer him to the med/surg floor, but Mr. Smith’s temperature rose to 101.6 F (38.3 C), and he exhibited hypotension and chills. Blood, urine, and sputum cultures were obtained. The physician prescribed broad-septum antibiotics.
1 Would Mr. Smith be considered to have a
3 I f blood culture results show CNS, which
2 Can Mr. Smith be considered to have
r. Smith’s sputum culture also shows P. ae4 M
CLABSI if the blood culture shows Pseudomonas aeruginosa isolated in one blood culture? a. No, P. aeruginosa appears in only one culture. b. Yes, he has laboratory confirmation and a central venous catheter (CVC). c. Maybe, if signs and symptoms persist. d. Maybe, depending on when the culture specimen was obtained.
a CLABSI if the blood culture result is coagu lase-negative staphylococci (CNS) in blood culture, and the same organism is found in another blood culture drawn 24 hours later? a. No, since CNS appears in only one culture. b. Yes, a CVC and symptoms of infection are present. c. Yes, a CVC, a laboratory-confirmed bloodstream infection (BSI), and symptoms of infection are present. d. No, diagnostic studies are needed.
other criteria must be met before Mr. Smith can be identified with CLABSI? a. He has fever, chills, or hypotension. b. He has a CVC, and antibiotics are ordered. c. There is a positive sputum culture with the same organism. d. Symptoms of BSI are present, a CVC is in use, and blood draws occurred within 48 hours of each other.
ruginosa. The chest X-ray showed infiltration and consolidation, which suggests pneumonia. Would this be a primary CLABSI? a. Yes, the patient has positive blood culture and a CVC. b. No, P. aeruginosa was also found in another site. c. Maybe, if the bacteria load is high. d. Maybe, it depends on the physician’s diagnosis.
1. Answer B. He has laboratory confirmation and a CVC. P. aeruginosa is a pathogen (not a skin contaminant). 2. Answer C. CLABSI can be identified from a common skin contaminant isolated in one blood culture if the signs and symptoms of infection are present, and the organism is not related to another infection site. 3. Answer D. If common skin contaminant is isolated from blood culture, other above criteria must be met. This organism also is not related to another infection site. 4. Answer B. The same organism was found at a site other than the bloodstream. This is a secondary BSI.
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Joining Efforts The Centers for Medicare & Medicaid Services identified 14 categories of hospital-acquired conditions in the Inpatient Prospective Payment System Fiscal Year 2013 Final Rule.19 Vascular catheter-associated infection is one of 14 categories. In addition, hospitals accredited by The Joint Commission must establish practices to prevent CLABSI.20 Preventing CLABSI is a national patient safety goal (NPSG 07.04.01): Use proven guidelines to prevent infection of the blood from central lines. This Joint Commission requirement covers short- and long-term CVC and peripherally inserted central catheter lines.20 Hospital administrators and the public are more aware than ever of the need to prevent these HAIs. CLABSI is associated with increased medical expenses, morbidity, and mortality. It is largely preventable with evidencebased guidelines and an increasing awareness of the nurse’s role. A CLABSI rate of zero is the goal; patient safety is the No.1 priority. OnCourse Learning guarantees this educational activity is free from bias. May Mei-Sheng Riley, MSN, MPH, RN, ACNP, CCRN, CIC, is an infection control consultant at Stanford Health Care and formerly clinical epidemiologist at Ronald Reagan UCLA Medical Center.
References 1. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections, 2011. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/ hicpac/pdf/guidelines/bsi-guidelines-2011.pdf. Accessed January 19, 2017. 2. Preventing central line-associated bloodstream infections: a global challenge, a global perspective. The Joint Commission Web site. https://www.jointcommission.org/assets/1/18/CLABSI_Monograph. pdf. Published 2012. Accessed January 19, 2017. 3. Zimlichman E, Henderson D, Tamir O, et al. Healthcare-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;23:173(22):2039-2046. doi: 10.1001/jamainternmed.2013.9763. 4. Central line infection. Institute for Healthcare Improvement Web site. http://www.ihi.org/topics/centrallineinfection/Pages/default. aspx. Accessed January 19, 2017. 5. Bloodstream infection event (central line-associated bloodstream infection and non-central line-associated bloodstream infection). Centers for Disease Control and Prevention Web site. http://www.cdc. gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf. Accessed January
CE476
How to Earn Continuing Education Credit 1. Read the Continuing Education article. 2. Go online to ce.nurse.com to take the test for $12. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at https://www.nurse.com/ sign-up for $49.95 per year.
Deadline Courses must be completed by 2/15/2019 3. If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer. 4. Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test. 5. All users must complete the evaluation process to complete course. You will be able to view a certificate on screen and print or save it for your records.
Accredited In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider #50-1489).” OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider #CEP16588.
19, 2017. 6. Ratz D, Hofer T, Flanders SA, Saint S, Chopra V. Limiting the number of lumens in peripherally inserted central catheters to improve
ONLINE
Questions
outcomes and reduce cost: a simulation study. Infect Control Hosp
Nurse.com/CE You can take this test online or select from the list of courses available. Prices subject to change.
Questions or for a complete listing of our courses Phone: 800-866-0919 Email: ce@nurse.com
Epidemiol. 2016;37(7):811-817. doi: 10.1017/ice.2016.55. 7. Lorente L, Jimenez A, Santana M, et al. Microorganisms responsible for intravascular catheter-related bloodstream infection according to the catheter site. Crit Care Med. 2007;35(10):2424-2427. doi: 10.1097/01.CCM.0000284589.63641.B8.
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IN THE OR
continuing education 8. Marschall J, Mermel LA, Fakih M, et al.
ed bloodstream infections in the ICU. N Engl
ington, D.C.: Association for Professionals in
Strategies to prevent central line-associated
J Med. 2006;355(26):2725-2732. doi: 10.1056/
Infection Control and Epidemiology; 2014.
bloodstream infections in acute care hospitals:
NEJMoa061115.
17. Compendium of strategies to prevent
2014 update. Infect Control Hosp Epidemiol.
13. Scott SK, Gohil SK, Quan K, Huang SS.
healthcare-associated infections in acute
2014;35(7):753-771. doi: 10.1086/676533.
Marked reduction in compliance with central
care hospitals. The Society for Healthcare
9. Riley MMS. Mosby’s PDQ for Infection Con-
line insertion practices (CLIP) when account-
Epidemiology of America Web site. http://
trol. St. Louis, MO: Mosby; 2009:75-81.
ing for missing CLIP data and incomplete line
www.shea-online.org/priority-topics/compen-
10. Sievert DM, Ricks P, Edwards JR, et al.
capture. Am J Infect Control. 2016;44(2):242-
dium-of-strategies-to-prevent-hais. Accessed
Antimicrobial-resistant pathogens associ-
244. doi: 10.1016/j.ajic.2015.09.007.
January 19, 2017.
ated with healthcare-associated infections:
14. Clean care is safer care. Infection preven-
18. Gorski L, Hadaway L, Haggle ME, Mc-
summary of data reported to the National
tion and control. World Health Organization
Goldrick M, Orr M, Doellman D. Infusion
Healthcare Safety Network at the Centers for
Web site. http://www.who.int/gpsc/en. Ac-
therapy standards of practice. J Infus Nurs.
Disease Control and Prevention, 2009-2010.
cessed January 19, 2017.
2016;39(Suppl 1):S1-S92.
Infect Control Hosp Epidemiol. 2013;34(1):1-14.
15. Bukhari SZ, Banjar A, Baghdadi SS, Baltow
19. Hospital-acquired conditions. Centers for
doi: 10.1086/668770.
BA, Ashshi AM, Hussain WM. Central line asso-
Medicare and Medicaid Services Web site.
11. Karlowsky JA, Jones ME, Draghi DC, Thorn-
ciated blood stream infection rate after inter-
https://www.cms.gov/medicare/medicare-fee-
sberry C, Sahm DF, Volturo GA. Prevalence
vention and comparing outcome with National
for-service-payment/hospitalacqcond/hospi-
and antimicrobial susceptibilities of bacteria
Healthcare Safety Network and International
tal-acquired_conditions.html. Updated August
isolated from blood cultures of hospital-
Nosocomial Infection Control Consortium
19, 2015. Accessed January 19, 2017.
ized patients in the United States in 2002.
data. Ann Med Health Sci Res. 2014;4:682-686.
20. 2016 hospital national patient safety goals.
Ann Clin Microbiol Antimicrob. 2004;3:7. doi:
doi: 10.4103/2141-9248.141499.
The Joint Commission Web site. https://www.
10.1186/1476-0711-3-7.
16. Crnich CJ, Maki DG. Intravascular device
jointcommission.org/assets/1/6/2016_NPSG_
12. Pronovost P, Needham D, Berenholtz S, et
infection. In: Grota P. APIC Text of Infection
HAP_ER.pdf. Accessed January 19, 2017.
al. An intervention to decrease catheter-relat-
Control and Epidemiology. 4th ed. Wash-
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OID FILLING THE VOID_ BY Don sadler
Recruiting & Retaining OR Nurses The nursing shortage in the U.S. could get worse before it gets better. Half-a-million seasoned nurses are expected to retire by 2022, according to the Bureau of Labor Statistics. This translates into the need for 1.1 million new nurses to replace those retiring and
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accommodate an expansion in the delivery of health care services. Nurse staffing challenges are especially daunting in the operating room. About half of all OR leaders say they are having problems recruiting perioperative nurses, notes ChrysMarie Suby, RN,
MS, the president and CEO of the Labor Management Institute. In addition, two out of three perioperative nurse leaders today are over 50 years old and one-fifth are over 60. About two-thirds of these nurse leaders say they plan to retire by 2022.
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A Top Priority Statistics like these should make OR nurse hiring and retention a top priority for health care organizations, says Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, the CEO and Executive Director of the Association of periOperative Registered Nurses (AORN). “A large number of perioperative nurse retirements are predicted in the next five years, which will cause the current nursing shortage to escalate,” says Groah. “This will result in a serious loss of the perioperative nursing knowledge and experience that are critical to safe patient care and optimal outcomes.” Making the challenges even more difficult is the fact that very little, if any, perioperative training is provided in nursing schools today. Groah says that while hospitals can count on recently graduated nurses to be clinically prepared to care for patients in medical surgical
“Nursing students today don’t get clinical exposure as part of their education,” he says. “So most hospitals have to train OR nurses on the job.” Due to this lack of training, Groah says that many recently graduated nurses are reluctant to seek out employment in specialty areas like the OR. “This puts the responsibility on health care facilities to either develop a training program that will result in competent perioperative nurses or recruit experienced perioperative nurses,” she says.
Periop 101 From AORN One of the most commonly used OR nurse training programs is AORN’s Periop 101: A Core Curriculum. According to AORN, this comprehensive, blended educational program is used by more than 2,500 health care organizations nationwide to recruit, educate and retain
“ RECENTLY GRADUATED NURSES ARE NOT PREPARED TO CARE FOR PATIENTS REQUIRING SURGICAL INTERVENTION BECAUSE NURSING SCHOOLS HAVE ELIMINATED SPECIALTY TRAINING FROM THEIR CURRICULA” – LINDA GROAH units, they can’t generally count on them to work in the OR. “Recently graduated nurses are not prepared to care for patients requiring surgical intervention because nursing schools have eliminated specialty training from their curricula,” says Groah. “Nursing school curricula is designed to prepare student nurses to pass the licensure exam, but not to work in specialty areas like the emergency department, critical care, labor and delivery unit, or perioperative areas,” she adds. David Taylor, MSN, RN, CNOR, the President of Resolute Advisory Group LLC, agrees.
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perioperative nurses. Periop 101 is based on AORN’s latest, evidence-based Guidelines for Perioperative Practice. According to Groah, the program combines a standardized, evidence-based online curriculum and textbook readings with hands-on skills labs and a clinical practicum. “It’s very resource-intensive and usually takes about six to seven months to complete,” says Groah. Taylor believes that health care organizations should have OR nurse training programs like Periop 101 running continuously at all times. He recommends a three-pronged approach to perioperative nurse
training that encompasses didactic and clinical experience with lab work. Visit www.aorn.org/periop101_OR to find out more about AORN’s Periop 101: A Core Curriculum. “To adequately train new OR nurses, health care organizations need to have a dedicated perioperative educator,” says Taylor. “But most don’t have someone who functions in this role on a daily basis.”
Maintaining a Work-Life Balance To attract and retain the perioperative nurses they need to keep their ORs running smoothly, Groah recommends that health care organizations focus on the things that are most important to OR nursing candidates. At the top of the list, she says, is maintaining a healthy work-life balance. “The results of the AORN 2017 salary survey reflect this,” she says. However, Taylor points out that the typical scheduling practices at many hospitals aren’t designed to allow for this. “Four nights of call a week and two weekends of call a month aren’t conductive to a healthy work-life balance,” he says. The AORN salary survey results also indicate that facilities need to put greater focus on paid time off and that there should be incentives for established nurses to remain in their jobs, adds Groah. The most frequently suggested motivator for retention mentioned in the survey retention bonuses. According to the survey, retention bonuses increased by just one percent last year, while incentive bonuses were up two percent and employee referral bonuses were up four percent. Taylor stresses the importance of strong perioperative leadership in hiring and retaining OR nurses. “Nurses often leave due to poor leadership,” he says. “Transformational leaders are better equipped to keep nurse retention levels high.” Creating the right kind of working environment is also critical to hiring and retaining high-quality WWW.ORTODAY.COM
Linda Groah, MSN, RN, CNOR, NEABC, FAAN, the CEO and Executive Director of the Association of periOperative Registered Nurses (AORN)
perioperative nurses. “AORN believes that creating a professional practice environment of safety is the most successful retention practice for health care facilities,” says Groah. A culture of safety includes effective communication and individual accountability. “It allocates appropriate resources and provides the necessary incentives and rewards to promote a healthy patient safety culture,” says Groah. “It also encourages the reporting of and response to errors with a focus on process improvement,” Groah adds. “A commitment to safety must be articulated at all levels of the organization and safety must be valued as a high priority – even at the expense of productivity.”
Partnering Together Groah recommends that OR directors partner with the health care facility’s human resources department and the CFO to develop a perioperative nurse hiring and retention plan. “The first step should be an assessment of the current staff and projected dates of retirement for senior staff members,” she says. “Using this information, OR directors should work with the CFO to develop a business case for recruiting OR nurses that includes adWWW.ORTODAY.COM
ChrysMarie Suby, RN MS, the president and CEO of the Labor Management Institute
equate time for orientation and training.” “The potential loss of revenue related to closing ORs due to a lack of staff should be a defining factor in assessing the return on investment of proactive staff planning,” she adds. Taylor concurs. “Over half of a hospital’s net revenue comes from perioperative services,” he says. “The OR is a hospital’s financial engine – the viability of many other hospital services depends on a financially healthy OR.”
David Taylor, MSN, RN, CNOR, the President of Resolute Advisory Group LLC
“OR leaders can’t be everywhere at all times and they shouldn’t try to be,” he says. “Team members at all levels should be empowered to make decisions,” Taylor adds. “This helps current OR leaders identify employees who are interested in higher level leadership positions but need some grooming.”
Succession Planning Included in proactive OR staff planning should be succession planning. “The nursing profession in general does not do a good job of grooming its next generation of leaders,” says Taylor. “There’s no question that OR managers and directors need to anticipate leadership turnover,” says Groah. “The wave of retirements that’s anticipated suggests a ‘grow from within’ approach to building a team that can withstand leadership departures.” Taylor believes that one of the most effective ways to develop OR nurses’ leadership skills is to empower them with greater responsibility for OR processes and outcomes. FEBRUARY 2018 | OR TODAY |
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COOKIE SANC SPOTLIGHT ON
BY MATT SKOUFALOS
t the age of five, Cookie Sanchez was hospitalized for a month with third-degree burns. While in recovery, she felt the compassionate attention of the nurses who tended to her, and from that moment, knew that she wanted to repay the kindness someday. At 13, she volunteered as a hospital candy striper, but was quickly frustrated by the limitations of the position (“I was only allowed to give water to the patients,” Sanchez recalled).
A
By 17, she was a single mother, and becoming a nurse suddenly became less of an aspirational career and more of an opportunity to provide a stable living for herself and her child. With focused intention, Sanchez completed her CNA certificate, and worked for a decade as a nurse’s aide. As the demands of her profession increased, Sanchez returned to school to complete her LPN license, and then again to get her bachelor’s degree in nursing (RN). With that education under her belt, she spent another 12 years working in a liver transplant unit at Lourdes Medical Center in Camden, New Jersey, one of the most dangerous cities in the country. “It was scary,” Sanchez said. “I said to myself, ‘I have a baby at home, I can only work night shifts because I have to take care of her during the day.’” She remembered that time in the
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ICU as “the most amazing 12 years of my life;” a balance of intimidating and rewarding experiences. Her patients were in need of such critical care that she would spend an entire 12-hour shift tending to one at a time. Sanchez later worked as a charge nurse, a case manager, and served on some leadership committees, but still searched for opportunities to give back to the local community from which Lourdes drew its patients. Last year, she left the ICU for a clinical manager’s role supervising home health aides at Bayada of Philadelphia, Pennsylvania, a job in which she feels more closely connected to changing people’s health habits before they fall ill. “What I do now, I love,” Sanchez said. “The struggle was on when I was 17. Now I’m 54 and the struggle is still on, but it’s getting better. I’m giving it all I got.” For Sanchez, education was one of the only ways to win that struggle, and it’s a message to which she frequently returns in her mentorship of younger nurses. In a family of 12 siblings, she’s the only one to have earned a college degree. She’s frequently leveraged her bilingual expertise in connecting with both clients and coworkers, and six years ago, joined the National Association of Hispanic Nurses (NAHN). Last year, she was named president-elect of its Philadelphia chapter, a position from which she hopes to help create more opportunity for young nurses who may
share her experiences. Sanchez said that she tells young working nurses, “It’s not enough to work and get paid,” and encourages them to carry forward the spirit of community education among their peers who are starting out in the field.
With better communication, Sanchez said she and her cohorts can help reduce the waste associated with ERfirst primary care, illnesses caused by contravening pharmaceutical regimens, and similar issues. A shortfall in money that once was available to pursue a career in nursing has left many young nursing students unqualified for entry-level positions, the requirements for which now may include bachelor’s degree programs. Part of the issue is that institutions may no longer fund advanced degree programs to the levels they once did; even veteran staff who may have been working in the field for years no longer have a guarantee of retaining their positions without completing higher-education WWW.ORTODAY.COM
CHEZ RN, BSN
curricula, she said. “I have a couple students in my organization who are having a hard time getting a job as a new nurse,” Sanchez said. “There’s such a shortage and yet because you’re a new nurse, they give you a hard time. We see a lot of graduate nurses who only have an associate degree, and a lot of places are looking for bachelor’s degrees; a lot of facilities are requiring a BSN. They’re sending people back to school to get a bachelor’s degree if they want to maintain their status [in management].” To that end, NAHN devotes a significant amount of time and effort collecting money to help more Hispanic nurses enter the field and retain their positions. Its fundraising typically generates scholarships for at least three students to continue their nursing education. Sanchez estimated that Hispanic nurses comprise about 15 percent of the national nursing population, and yet the need for bilingual caregivers to address health education concerns and tend to non-English-speaking patients has never been greater: that’s why NAHN also provides money to subsidize public health screenings. “When we do health screenings, we ask patients, ‘What are your numbers?’ ‘Do you have a history of high blood pressure?’ and they don’t understand,” Sanchez said. “That’s not enough for us. That’s not education.” With better communication, WWW.ORTODAY.COM
Sanchez said she and her cohorts can help reduce the waste associated with ER-first primary care, illnesses caused by contravening pharmaceutical regimens, and similar issues. “We need to help them understand the medication they’re taking; try to keep them away from the emergency room; try to save the hospital some money,” she said. “I see these single women who are out there trying to make a living,” Sanchez said. “I get to encourage these girls to continue their education. We need them to understand that there’s a [nursing] shortage, the language barrier is important, and we need to educate and give back to our community.” After beginning her career at a time when nurses primarily were hired to take orders from physicians, these are issues to which she could never have foreseen herself having a hand in shaping the solutions. “We’ve come a long, long way,” she said. FEBRUARY 2018 | OR TODAY |
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OUT OF THE OR fitness
Are Your Sleep Routines familycircle.com alling asleep at night might be the hardest thing you do all day. Thanks to “go-go-go” lives filled with work deadlines, family responsibilities and home chores, it’s no wonder many of us struggle with insomnia. Problem is, many of our favorite ways to wind down at night may actually worsen our sleep. Discover which sleep habits keep you up at night and learn how to ditch them so you wake up feeling more energized than ever.
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Sleep crutch No. 1: A goblet of vino. Although alcohol can cause drowsiness and help you fall asleep faster, it also throws off your body’s sleepwake cycle. Booze relaxes your throat muscles and rushes you into slumber, making it more likely that you’ll snore or have difficulty breathing. Alcohol is also a diuretic, which increases your odds of getting a wake-up call from your bladder. In addition, it’s likely you won’t feel restored the next morning, as alcohol shortens the amount of time you spend in the REM (rapid eye movement) sleep phase, which is crucial for rebuilding next-day memory and concentration levels. The solution? Finish that glass of merlot at least three hours before bedtime and unwind with a relax-
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Keeping You Up at Night? ing activity like reading or light yoga instead. “You may miss its calming effects, but you’ll eventually teach your brain to power down on its own,” says Jay Puangco, M.D., service chief at the Judy & Richard Voltmer Sleep Center at Hoag Hospital in California.
Sleep crutch No. 2: Nodding off in front of the TV. Zoning out in front of the tube can actually stimulate your brain, making it even harder to unwind. In addition, electronics (including tablets and cellphones) emit blue wavelengths that inhibit your body’s release of melatonin, the hormone that helps you prepare for sleep. To solve this problem, remove the TV from your bedroom. Turn it off at least 30 minutes before bed, and avoid staring at a tablet, phone or computer before bed.
Sleep crutch No. 3: Tackling your to-do list. We’re all guilty of trying to squeeze in chores after everyone else is in bed, but finishing your to-do list before bed is a surefire way to increase your stress level. “You can’t zoom around at 80 miles per hour and then go right to sleep,” says Ruth Benca, M.D., Ph.D., a sleep specialist and head of psychiatry and human behavior at the University of California-Irvine School of Medi-
cine. “You need to unwind, otherwise you tend to ruminate on the day’s worries and stresses.” Instead, aim to finish the to-do list before dinner. Any tasks you don’t complete can wait until tomorrow. Planning out when you’ll take on bigger projects (like researching a family vacation) can also keep you on track.
Sleep crutch No. 4: Earplugs – to block out a snoring spouse. If a partner’s snoring wakes you in the night (especially if punctuated by pauses in breathing), it may signal sleep apnea, a serious condition that can increase the risk of heart disease. Seeking treatment is essential for both your partner’s health and your own. To remedy this situation, talk to your partner about scheduling a doctor’s appointment or seeing a sleep specialist who will examine his/her nose and throat and may recommend an overnight sleep study. With snoring and sleep apnea in check, you’ll both rest easier.
Family Circle offers family-friendly recipe ideas, health advice, and plenty of content for all members of the family to enjoy together. Online at www.familycircle.com.
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OUT OF THE OR health
Should You Forget the BY MARILYNN PRESTON
Meditation App?
ormally, reporting on the art and science of happiness makes me smile. Why? Because happiness turns out to be a learnable skill, unlike, in my case, navigating Facebook.
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Not every one of us will live a happy life, and none of us can be happy every moment, but for many women and men who struggle with unhappiness, the battle ends when you fully realize, “You know what? Happiness is a conscious choice.” Or at least you can choose to be happier, and that’s why we have a 24/7, on-demand, make-me-joyfulnow happiness industry in America that includes thousands of happiness apps, books, adult beverages, retreats and happiness experts, not to mention assorted support animals. Happiness is a booming business, and I consider it my business because happiness is rooted in the mind-body connection. That’s the beautiful takeaway from “The Molecules of Emotion,” a landmark book written in 1997 by Candace Pert. In her pioneering research, this hardcore, renowned neuroscientist with the National Institutes of Health proved that when you experience a deep sense of emotional well-being – through yoga, meditation and mindfulness – your entire body gets bathed in “bliss chemicals”
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(endorphins) of your own making. And what else gets these bliss chemicals flowing? Well, that’s where we jump to the work of British journalist Ruth Whippman, the author of “America the Anxious: How Our Pursuit of Happiness Is Creating a Nation of Nervous Wrecks.” She wrote a commentary in The New York Times recently called “Happiness Is Other People,” based on years of researching and writing her book. There’s too much focus on happiness as “an internal, personal quest, divorced from other people,” she writes. Americans are engaging in the pursuit of happiness in larger numbers than ever, but she believes they are going about it in the wrong way. “The idea that happiness should be engineered from the inside out, rather than the outside in, is slowly taking on the status of a default truism,” she complains. Resist, she says. This approach to happiness is leading people to “a journey of self-discovery,” Whippman warns, “with the explicit aim of keeping each person locked in her own private emotional experience.” Whippman condemns that approach as an “isolationist philosophy,” one that is shifting people away from spiritual practice “as a communitybased endeavor to a private one, with silent meditation retreats, mindfulness
“The idea that happiness should be engineered from the inside out, rather than the outside in, is slowly taking on the status of a default truism.” apps and yoga classes replacing church socials and collective worship.” “Forget the meditation app,” her article advised. “Self-help gurus urge us to look within, but joy in life is elsewhere.” Oh, really? You’ve got an important point to make Ms. Whippman – and I’ll make it for you in a moment – but it’s a mistake to ignore the importance of meditation apps, mindfulness and, God forbid, yoga. It’s misleading, and, yes, it made me unhappy. The path to personal happiness, to connecting with others, begins with self-discovery. Mindfulness and meditation aren’t the enemy. They’re focusing skills to help us quiet the mind and open our heart. When you know and accept yourself, you are more open to knowing and loving others. So it’s not either-or. It’s both, with WWW.ORTODAY.COM
OUT OF THE OR health
happiness coming from a journey of self-discovery and a recognition that connecting with other humans is a huge part of human happiness. “Our happiness depends on other people,” Whippman writes, though the italics are mine. “Study after study shows that good social relationships are the strongest, most consistent predictor of a happy life.” “Neglecting our social relationships is actually shockingly dangerous to our
health,” Whippman goes on. “A lack of social connection carries with it a risk of premature death comparable with that of smoking and is roughly twice as dangerous to our health as obesity.” That’s a wow, isn’t it? “The most significant thing we can do for our well-being is not to ‘find ourselves’ or ‘go within,’” she concludes, running off the rail. “It’s to invest as much time and effort as we can into nurturing the relationships we have with the
people in our lives.” Ruth Whippman is making a crucial point about happiness. But I think she misses the mark when she ridicules “going within.” Do both, and if you need a happiness app to get you to your cushion 10 minutes a day, that’s good, too. Marilynn Preston is the author of Energy Express, America’s longest-running healthy lifestyle column. For more on personal well-being, visit www.MarilynnPreston.com.
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59
OUT OF THE OR nutrition
Evidence-Based
Approaches for Weight Loss
By Matt Ruscigno, M.P.H., R.D.
osing weight and getting healthier is a common goal among Americans; we spend $60 billion dollars a year on weight loss books, gym memberships, apps, programs and special diet foods. Yet, collectively we are getting heavier, which leads to an increased risk of chronic diseases such as heart disease, type 2 diabetes and cancer. The answer to weight loss is multifaceted, but a good starting point is understanding calories.
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Calories are the source of energy used by the human body and are found in foods in the form of carbohydrates, proteins and fats. We need energy to perform basic bodily functions and even more if we exercise. Excess calories are stored as body fat, essentially reserved energy. In some ways, the science of losing weight is simple: expend more calories than are consumed and your body will use body fat for energy. You can do this by eating less or by exercising more. The catch is that we don’t live our lives in a lab. Food tastes good, we are creatures of habit, and we like to indulge at social gatherings. Life gets in the way. So, what do you do? Here are a few, evidence-based approaches for weight loss.
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Forget dieting; make a lifestyle change Diets are often measured by shortterm results and don’t hold up over the long-term. You’re better off changing your lifestyle with sustainable strategies that will lead to long-term health. “Eating according to internal cues, including hunger, fullness and satisfaction, rather than external cues such as dieting, food rules and cultural pressures, helps us build trust in our eating habits and is most likely to lead to a stable weight,” says Taylor Wolfram, M.S., R.D., a Chicago-based dietitian.
Make a goal It should be S.M.A.R.T.: Specific, Measurable, Achievable, Realistic and Timely. If you make a specific, measurable goal, you can look back on your week and know if you accomplished it or not. Then adjust your goal if it’s unrealistic or if you are ready for another goal. Here’s a simple one: Eat three servings of legumes per week.
Choose high-fiber foods Vegetables, beans and whole grains are high in fiber and volume and low in calories. Fiber increases satiety, making you feel full while eating less. The extra volume in these foods mean you can eat more of them, while consuming fewer calories. Start by adding a
bean soup or salad to your dinner to help you feel more satisfied with the meals you typically enjoy.
Watch added fats in food preparation Fat – no matter whether it’s olive or coconut oil – is the most calorically dense food ingredient. Oil (at 120 calories per tablespoon) weighs in at over 4,000 calories per pound, while vegetables are under 200 calories per pound.
Don’t focus on the scale Changing your lifestyle takes time, and there’s more to good health than a number on a scale. Building muscle can add weight, and weight loss isn’t always a straight line down. Don’t get caught up in the micro changes if you are making the macro ones. Wolfram adds, “Body weight is very complex with countless contributing factors, most of which are beyond our control. Science tells us healthy lifestyle behaviors include physical activity, eating plenty of fruits and vegetables, and not smoking. These are more strongly linked to health outcomes than is weight.”
4 Weight Loss Myths Juicing helps you lose weight. Juicing is not a preferred weight loss strategy, because replacing meals with WWW.ORTODAY.COM
OUT OF THE OR nutrition
juice isn’t a sustainable habit. Additionally, when fruits and vegetables are juiced, components such as fiber are lost, but the simple sugars remain. Drinking the equivalent of five fruits is not the same as eating those five fruits. Drinking calories for weight loss can be problematic because it eliminates the chewing process, making overconsumption easier. Drinking 500 calories does not provide the same satiety as eating 500 whole food calories.
Results may vary.
Fasting is required for weight loss.
There are no magical fat-burning foods.
A newer trend in weight loss is fasting or intermittent fasting. The former has long been disproven as a way for successful weight loss because most individuals return to the eating habits that caused the weight gain to begin with. Intermittent fasting, which involves going a set period of time between meals, may help you learn hunger cues, but there’s not enough research to know if this works in the long-term.
No one food significantly increases metabolism or triggers fat burning. That’s what makes the diet industry so appealing. It is difficult to lose weight successfully, so the appeal of magic foods, from coconut oil to superfruit, is strong.
Ask about weight loss and you’ll get a number of success stories, which adds to the confusion. It’s important to remember that what worked for your cousin, may not work for you. And often people don’t realize all of the changes they have made or the support system they have in place. These factors can greatly influence success beyond simple diet strategies.
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OUT OF THE OR
Recipe
recipe
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.
the
62 | OR TODAY | FEBRUARY 2018
For the sauce: • • • • • •
•
• •
1 cup diced dried apricots 1/2 cup dried cranberries 1 cup apple juice 1/2 cup water 2 tablespoons unsalted butter 2 leeks, white and light green part, cleaned and finely chopped 1 medium Gala or Granny Smith apple, peeled, cored, and chopped into 1-inch pieces 1 cup beef or chicken broth Salt and freshly ground black pepper
For the pork chops: • 1 tablespoon unsalted butter • 2 tablespoons oil • 6 center cut pork chops with bone on, 1 1/2 inches thick about 3/4 pound each • Salt and freshly ground black pepper • 1/2 cup apple brandy • 2 teaspoons whole grain mustard • 2 tablespoons finely chopped parsley, for garnish
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OUT OF THE OR recipe
Pork Chops
are perfect for quick meals I’m always looking for easy dinners to pull together. Pork chops are perfect for quick meals since they don’t take long to prepare. They come from the loin portion of the pig and are available boned and with the bone attached. I prefer the center cut rib chop with the bone attached because the bone adds more moisture to the meat when you cook it; and it also looks pretty. These chops are sautéed and finished with an apple and dried fruit sauce that is as delicious as it is easy to prepare. If you can find Kurobuta pork chops, they are worth the extra price tag. Kurobuta (Japanese black hog) pork, bred from Berkshire stock, is prized for its dark meat and rich flavor. American Kurobuta pork is lean, yet still has small,
fine streaks of marbling that produce a sweet, tender and juicy result. You can usually find this variety at fine supermarkets or meat markets. While many recipes suggest cooking pork to an interior temperature of 160 F, I have found that is simply too high. The pork should be slightly pink and at 145 F for both optimum flavor and texture. Trichinosis, a parasite found in pork, dies at 137 F so cooking past that temperature should assure you that your dish would be safe as well as delicious. Serve these chops with simple buttered noodles, spaetzle or roasted potatoes. A California zinfandel, a gewurztraminer or a big chardonnay would make a nice wine accompaniment.
Pork Chops with Apple and Dried Fruit Sauce Serves 6 1.
To start the sauce: Bring the dried fruit, apple juice and water to a boil on high heat. Remove from the heat and let soften for 10 minutes. 2. In a large skillet heat 2 tablespoons of butter on medium-high heat. Sauté the leeks for about 5 to 7 minutes or until softened and lightly browned. Add the apple pieces and sauté another 2 to 3 minutes or until nicely coated. Add the softened fruit mixture and broth. Simmer on medium heat for 5 more minutes or until slightly thickened. Add salt and pepper and taste for seasoning. Reserve. 3. In another large skillet heat 1 tablespoon of butter and the 2 tablespoons of oil in the pan on medium-high heat. Season the pork chops with salt and pepper. Sauté the chops for about 5 minutes and then turn over with tongs. Continue cooking until WWW.ORTODAY.COM
browned and just cooked through, about another 3 minutes. Place the chops on a platter and cover with foil. 4. Discard the drippings. Over medium heat (with the overhead fan turned off), add the apple brandy to the pan and deglaze the pan by scraping up the brown bits. Add the reserved fruit sauce and mustard, and bring to a simmer, stirring, for 3 minutes (or until the alcohol has burned off). Add salt and pepper and taste for seasoning. 5. Return the pork chops to the pan and spoon sauce over the chops. Braise for about 3 more minutes or until the pork is heated through but still tender. Garnish with parsley, and serve immediately.
FEBRUARY 2018 | OR TODAY |
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OUT OF THE OR pinboard
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iness; happiness p p ha to ay w no is “There Dyer is the way.”– Wayne
OR TODAY JANUARY CONTEST WINNER Marilyn Frazier shared these photos from Akron Children’s Hospital.
64 | OR TODAY | FEBRUARY 2018
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The News and Photos that Caught Our Eye This Month
OUT OF THE OR pinboard
Book Provides Strategies for Integrating Ambulatory Care Fear: The Hidden Killer From stand-alone small rural hospitals to facilities that are part of a multiAlicae. Ximost apellen ditiam ut hospital system, challenges exist to voluptatur, tem apiti ditium eum maintain market strength as patients eosae inum, evelestibus. migrate toward larger centers for care. Fero voluptur, officipsum Greenbranch Publishing announces the quianduntem laborepeles ilia book, “Integrated Ambulatory Care: Key
for success as well as gold standard accreditation achievement. Itate conem faccaec temporem • Time-tested medical office space as eum cusaepre dolluptatios design that leads to an economically efdebis est, corrum esedio occus ficient practice. maio temolupti odis pre quae• Tools to calculate primary care rum quaeperumet audita exped access based on patient panel size and
Growth Strategies for Small and Rural Ut inctorum eos sedisciendae Hospitals,” by James Hamilton, MBA, cum reptatiantia si offic tendani FACMPE, to provide health systems the musapernat labori nos et fuga. ability to integrate ambulatory care in Et velibus accum fuga. Et incipic a manner which is profitable, clinically itatis sit pa volor aspisquibus effective, time-efficient and reflective of id maximincia dolupiendis best practices. et quissum et, saped et quid Topics included in the book are: quidunt, omnim fuga. Ovit, con • Comprehensive strategies to mainnem. Im vel et volut vernatistain and grow marketshare in service cius volo mosae ventisquia nos lines: women’s health, musculoskeletal es dolorita cumque re ipsam services and chronic disease managevid ut fugitatem eius pe rem. ment, as well as others. • Employing physicians is costly. The book provides benchmark architecture
hours worked. core ped quibus, estestis di teni• Formulas and annual percent of tatiate voluptur si conseribus es new patients needed (by specialty) to des nulparc imolorro offic tem maintain a viable practice. es molorro iumqui bernatio. Unti • Data and methodology to calculate consectotae. Quibus explabordownstream revenue from physician est, offici sus eum faceria ea ea practices. simus aut esed ut eum delitatur • Proven methods in customer sermodipis dolores etur re, volvice implementation and action plans ecest, et recatur, et venihiliquam with metrics for customer knowledge, nam acepudande eosam, et access, education/promotion and paquam evelita tionsequam el tient experience. ipisquae. Itaspelique quist, od • Strategies for developing a successful primary care medical home.
dolum venimpo rehent.
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velestorro hospital leadofficiendunt ership teams et doluptiaJames Ha from an MBA, F milton, nis molora ACMPE independent quae dolorio freestandnempoing small/rural hospital to similar facility rero corestrum fugitii sitatium leaders that are owned and operated rerfero od et por aped quist by a larger system. Both struggle with officta sperovid mossitiam, tem organizational goals, but bottom line faceptatur aut aut qui sinimus success in gaining market share and molorioratur aut ut ersperibus, patient volumes will translate into a nonsed qui dolupti berit, omnihighly successful organization that is hil ipsunt. a common goal for any organization regardless of ownership.
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maximus duciand aecepereped quam et laborem core velestordebis est, corrum esedio occus ro officiendunt et doluptianis age, smoking, diabetes and pre-existor allowing the dog to lick maio temolupti odis apre molora quae dolorio nempoing conditions to name few.quaePeople them on the mouth. don’t their gumaudita infection can When kissing rum realize quaeperumet exped rero2. corestrum fugitiisomeone sitatiumwho worsen other healtheos conditions. might haveaped gum disease, molores reiumet num qui rerfero od et por quist chew Dockins is so passionate about xylitol gum or suck ontem nanosilcore ped quibus, estestis di teni- officta sperovid mossitiam, spreading the word about the farver lozenges, which kills tatiate voluptur si conseribus es faceptatur aut aut qui sinimusoral reaching health impacts of gum disbacteria. des nulparc imolorro offic tem molorioratur aut ut ersperibus, ease that she quit her job as a surgical 3. Refrain from kissing people es molorro iumqui bernatio. Unti nonsed qui dolupti berit, omnihil nurse to bring this emerging issue to they don’t know who may consectotae. Quibus explaboripsunt. have gum disease. light among the medical community est,the offici sus eum Aligend uciistrum fugiasperiodonand population atfaceria large. ea ea 4. Know their partner’s simus aut esedCollege ut eumofdelitatur The American Surgeons eictat. tal probing scores, which meamodipis dolores etur re, volTest, conseribus. Upiende and Surgical Infection Society has sure the depths of the gum ecest, et recatur, et venihiliquam llandemdisease olorempockets. nos et as aut established that allowing patients to Any probing have surgeryeosam, with an et active 4 or above indicates periodonnamelective acepudande veritat etusapis doluptatibus infection is placing surgical patients tal disease. quam evelita tionsequam el esto quate volupta vellaud igenat increased risk for postoperative 5. Have routine dental re examiipisquae. Itaspelique quist, od dis doluptatem resectate pra
5 Ways totem Prevent Getting Diseasedolluptatios voluptatur, apiti ditium eum asGum eum cusaepre eosae inum, evelestibus. Few people realize that gum disease Fero voluptur, officipsum is a communicable infection that can be quianduntem transmitted by kissing their dog laborepeles ilia or allowing their furry friend to lick their dolum venimpo rehent. mouth. Another even likelier way to Ut inctorum eos sedisciendae contract this infection is by kissing a cum reptatiantia si offic tendani date or partner. “Every time you kiss musapernat labori nos et fuga. someone you may be exchanging Et velibus accum fuga. Et incipic some of this potentially dangerous itatis sit pa volor aspisquibus mouth bacteria,” says Jeanne Dockins, maximincia dolupiendis RN,idBSN. et quissum et,out saped quid Dockins points that et untreated quidunt, Ovit, con gum disease omnim can leadfuga. to heart disease, nem. Im vel et volut vernatisAlzheimer’s, cancer and death. Dockins cites a statistic from David cius volo mosae ventisquia nos Verity, DDS, who says that more than es dolorita cumque re ipsam 40 vid percent of the population ut fugitatem eius pehas rem. some degree of periodontal disease and having class 3 or 4 periodontal disease is like having an infection as large as the palm of your hand. The severity of gum disease increases with
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infection. Dockins points out that periodontal disease is an active infection. To avoid getting periodontal disease, Dockins advises people to: 1. Refrain from kissing their dog
nations and know their own periodontal probing scores. These are just a few tips Dockins recommends for reducing the risk of contracting gum disease.
FEBRUARY 2018 | OR TODAY |
65
INDEX
advertisers
Alphabetical AIV Inc.………………………………………………………… 15 Arthroplastics, Inc.……………………………………… 23 ASCA…………………………………………………………… 48 Avante Health Solutions…………………………17-19 C Change Surgical……………………………………… 13 Cincinnati Sub-Zero…………………………………… 57 Cygnus Medical……………………………………………… 9 D. A. Surgical……………………………………………… 67
Diversey ……………………………………………………… 49 FOBI Medical……………………………………………… 59 Healthmark Industries Company, Inc.……… 4 Innovative Medical Products…………………… 68 Jet Medical Electronics Inc……………………… 26 MD Technologies inc.………………………………… 61 Medi-Kid Co.………………………………………………… 29 Microsystems……………………………………………… 27
Mobile Instrument Service & Repair……… 39 Pacific Medical…………………………………………… 31 Paragon Services………………………………………… 32 Ruhof Corporation…………………………………… 2, 3 TBJ Incorporated…………………………………………… 5 TIDI C-Armor………………………………………………… 6 USOC Medical…………………………………………………21
Ruhof Corporation……………………………………… 2,3 TBJ Incorporated…………………………………………… 5 TIDI C-Armor………………………………………………… 6
REPROCESSING STATIONS
INSTRUMENT STORAGE/TRANSPORT Cygnus Medical……………………………………………… 9
Healthmark Industries Company, Inc.……… 4 TIDI C-Armor………………………………………………… 6
INSTRUMENT TRACKING
SINKS
categorical ANESTHESIA Paragon Services………………………………………… 32
ASSET MANAGEMENT Microsystems……………………………………………… 27
ASSOCIATION ASCA…………………………………………………………… 48
CARDIAC PRODUCTS C Change Surgical……………………………………… 13 Jet Medical Electronics Inc……………………… 26
CARTS/CABINETS Cincinnati Sub-Zero…………………………………… 57 Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.……… 4 TBJ Incorporated…………………………………………… 5
Microsystems……………………………………………… 27
MONITORS Pacific Medical…………………………………………… 31 USOC Medical…………………………………………………21
ONCOLOGY Avante Health Solutions…………………………17-19
OR TABLES/BOOMS/ACCESSORIES
Medi-Kid Co.………………………………………………… 29
Arthroplastics, Inc.……………………………………… 23 D. A. Surgical……………………………………………… 67 Innovative Medical Products…………………… 68
CS/SPD
OTHER
CRANIOFACIAL RECOVERY PRODUCTS
Microsystems……………………………………………… 27
AIV Inc.………………………………………………………… 15
DISINFECTANTS
PATIENT MONITORING
Cygnus Medical……………………………………………… 9 Diversey ……………………………………………………… 49 Ruhof Corporation…………………………………… 2, 3
ENDOSCOPY Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.……… 4 Mobile Instrument Service & Repair……… 39 Ruhof Corporation……………………………………… 2,3
ERGONOMIC SOLUTIONS Diversey ……………………………………………………… 49
GENERAL AIV Inc.………………………………………………………… 15
IMAGING Avante Health Solutions…………………………17-19
INFECTION CONTROL Cygnus Medical……………………………………………… 9 Diversey ……………………………………………………… 49 Healthmark Industries Company, Inc.……… 4
66 | OR TODAY | FEBRUARY 2018
AIV Inc.………………………………………………………… 15 Avante Health Solutions…………………………17-19 Jet Medical Electronics Inc……………………… 26 Pacific Medical…………………………………………… 31 USOC Medical…………………………………………………21
PEDIATRICS Medi-Kid Co.………………………………………………… 29
POSITIONING PRODUCTS Cygnus Medical……………………………………………… 9 D. A. Surgical……………………………………………… 67 Innovative Medical Products…………………… 68 Medi-Kid Co.………………………………………………… 29
RENTAL/LEASING Avante Health Solutions…………………………17-19
REPAIR SERVICES Cygnus Medical……………………………………………… 9 Jet Medical Electronics Inc……………………… 26 Mobile Instrument Service & Repair……… 39 Pacific Medical…………………………………………… 31
TBJ Incorporated…………………………………………… 5
SAFETY
TBJ Incorporated…………………………………………… 5
STERILIZATION Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.……… 4 TBJ Incorporated…………………………………………… 5
SURGICAL Avante Health Solutions…………………………17-19 FOBI Medical……………………………………………… 59 TIDI C-Armor………………………………………………… 6
SURGICAL INSTRUMENT/ACCESSORIES Arthroplastics, Inc.……………………………………… 23 C Change Surgical……………………………………… 13 Cygnus Medical……………………………………………… 9 FOBI Medical……………………………………………… 59 Healthmark Industries Company, Inc.……… 4
SURGICAL TABLES/LAMPS FOBI Medical……………………………………………… 59
TELEMETRY AIV Inc.………………………………………………………… 15 Pacific Medical…………………………………………… 31 USOC Medical…………………………………………………21
TEMPERATURE MANAGEMENT C Change Surgical……………………………………… 13 Cincinnati Sub-Zero…………………………………… 57
ULTRASOUND Avante Health Solutions…………………………17-19
WARMERS Cincinnati Sub-Zero…………………………………… 57
WASTE MANAGEMENT MD Technologies inc.………………………………… 61 TBJ Incorporated…………………………………………… 5
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