OR Today - April 2018

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Sterile Processing

Claudia Pianti

The Flu

PRODUCT FOCUS

SPOTLIGHT ON

HEALTH

APRIL 2018

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OR TODAY | April 2018

contents features

54 CAIP: CERTIFIED AMBULATORY INFECTION PREVENTION

Certified Ambulatory

Hospital infection preventionists have long been able to obtain the Certification in Infection Control and Prevention, or CIC, credential. But a similar credential hasn’t been available for infection preventionists who work in ambulatory surgery centers (ASCs). Fortunately, this is about to change. Earlier this year, the Board of Ambulatory Surgery Certification (BASC) announced the creation of the Certified Ambulatory Infection Prevention, or CAIP, credential.

Infection Prevention

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Dräger was founded in 1889 and has grown into a worldwide enterprise with long-term success predicated on a value-oriented corporate culture with four central strengths: close collaboration with customers, the expertise of its employees, continuous innovation and outstanding quality.

The goal of this anticoagulant continuing education program is to inform nurses of current care practices for patients on anticoagulation therapy in the hospital. After studying the information presented here, readers will be able to Identify the most common anticoagulants for hospital patients.

Cygnus Medical provides innovative medical products and services. A leader in the industry, Cygnus Medical does more than listen to customers. The company develops unique, industry-first solutions to specific problems found in hospitals and health care facilities.

COMPANY SHOWCASE

CE ARTICLE

CORPORATE PROFILE

OR Today (Vol. 18, Issue #04) April 2018 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 302691530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530.

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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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Learn about Claudia Pianti’s career path as a nurse!

Homemade French Fries

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INDUSTRY INSIGHTS 10 News & Notes 22 CS/SPD 24 ASCA 26 Webinar Recap

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instrument channel dryer

INDUSTRY INSIGHTS

news & notes

McKesson MedicalSurgical to Offer New Sysmex Device

McKesson Medical-Surgical and Sysmex America have announced plans for McKesson to be the exclusive distribution partner for Sysmex’s new XW-100 automated hematology analyzer, the first Clinical Laboratory Improvement Amendments (CLIA)-waived, complete blood count (CBC) diagnostic instrument. Once prepared for each day’s use, the Sysmex XW-100 allows health care professionals to provide patients with blood test results in as few as three minutes.

“The XW-100 is an exciting health care innovation that will help to improve quality of care, practice efficiency and patient satisfaction,” said Doug Shaver, senior vice president and general manager of laboratory at McKesson Medical-Surgical. “Sysmex’s XW-100 is a compact, accurate and reliable device that is incredibly easy to use.”

The new Sysmex instrument’s ease of use makes it possible for tests to be conducted by in-house health care professionals in just a few easy steps, without the certification required for the operation of more complex diagnostic equipment. The XW-100 offers stepby-step, on-screen guided prompts and instructions, and operational safety checks to ensure that the user does not require any formal training. Its innovative software contains safety lockouts, fail-safe and alert mechanisms to provide accurate results.

While the XW-100 will be introduced in select medical practices next month, its full launch is expected in the spring of 2018. •

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3M Submits 510(k) Application for Rapid Steam Sterilization Assurance 3M has announced its submission for 510(k) clearance with the U.S. Food and Drug Administration (FDA) for its Attest Super Rapid System for Steam Sterilization, which will provide biological indicator (BI) results in 24 minutes. The clearance of a faster readout time for steam will continue to enhance patient safety while increasing workflow advantages for sterilization professionals.

“The focus of our sterilization science at 3M is on increasing patient safety through every means possible,” says Srini Raman, 3M business director of device reprocessing. “One of the best ways we can do that is to make it easy for sterilization departments to know that every load of medical instruments has met standards for sterilization before they’re released for surgery. We introduced a 24-minute readout for VH202 in July and it was met with great market excitement. Our next goal was to take this same science and apply it to steam sterilization monitoring, which 3M has been a progressive leader in for over 40 years.”

The addition of the 3M Attest 490 Auto-reader to 3M’s sterilization portfolio, pending 510(k) clearance, will mean customers can count on 3M for a simplified, standardized approach to BI processing for both steam and VH2O2 results in just 24 minutes.

The new system will utilize existing hardware and will continue to use the same BI technology. •

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INDUSTRY INSIGHTS

news & notes

AORN Releases New and Revised Guidelines for 2018 The Association of periOperative Registered Nurses (AORN) has published the 2018 Guidelines for Perioperative Practice with five updated guidelines, as well as a completely new guideline that addresses team communication.

Guidelines for Perioperative Practice, published each January, is a collection of 32 guidelines that provide evidence-based recommendations to deliver safe perioperative patient care and achieve workplace safety.

The Guideline for Team Communication is the first evidence-based guideline for effective communication in the perioperative environment. This new guideline expands upon and supersedes the Guideline on Transfer of Patient Care Information.

“Every AORN guideline recommends team involvement and shared communication with all stakeholders on the perioperative team, yet research still identifies ineffective team communication as a common cause of adverse events,” said Ramona Conner, MSN, RN, CNOR, editor-

in-chief of AORN’s Guidelines for Perioperative Practice.

“Understanding the evidence supporting strategies to strengthen team communication is critical for teams to successfully implement all AORN guidelines for safe perioperative care.”

2018 highlights include the following: • New – Guideline for Team Communication • Updated – Guideline for Positioning the Patient • Updated – Guideline for Medication Safety • Updated – Guideline for the Prevention of Venous Thromboembolism • Updated – Guideline for Medical Device and Product Evaluation • Updated – Guideline for Manual Chemical High-Level Disinfection. • For more information, visit www.aornbookstore.org/Product/Detail/MAN018.

ChartWise Medical Systems Receives Category Leader Distinction ChartWise Medical Systems Inc. has been recognized by health care research and analysis organization KLAS for excellence in the clinical documentation improvement technology space.

For the third consecutive year, ChartWise has been named a category leader in the clinical documentation improvement software segment in the 2018 Best in KLAS: Software & Services report. The category leader designation is reserved for vendor solutions that lead select market segments in which at least two products meet a minimum level of KLAS Konfidence.

ChartWise received an overall KLAS score of 91.6 for the organization and its flagship ChartWise 2.0 CACDI software

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solution. Final KLAS scores are a composite of a detailed analysis of the industry and the products, services and technologies currently available.

“Category leader is more than a ranking; it is a recognition of vendors committed to delivering superior solutions,” said Adam Gale, president of KLAS. “It gives voice to thousands of providers who are demanding better performance, usability and interoperability in healthcare technology.” • For more information, visit www.chartwisemed.com.

APRIL 2018 | OR TODAY |

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INDUSTRY INSIGHTS

news & notes

Maquet Moduevo Ceiling Supply Unit Product Line Hits U.S. Getinge has announced the U.S. launch of its Maquet Moduevo ceiling supply unit product line. These ceiling supply units have a number of new technical innovations that address the risk management needs of hospital operating rooms (OR), intensive care units (ICU) and emergency departments (ED).

Moduevo ceiling units are designed to help hospitals enhance efficiency by allowing staff to create customizable workstations to meet their changing needs. This helps staff simplify daily tasks and streamlines clinical workflows, thereby increasing productivity in operating rooms, intensive care

units and other health care environments and, in turn, lowering operating costs.

Today’s health care organizations must operate as efficiently as possible in an ever-changing environment while balancing budgets without compromising the quality of care. Given the need to meet these imperatives, raising productivity is crucial – and demands imaginative solutions,” said Chris Odom, president, surgical workflows at Getinge. “Moduevo represents a significant evolution in our ceiling supply unit offering. We designed this product line to have a best-in-class range of features and capabilities, and

to ensure that vital utilities and equipment are easily accessible so hospital staff can configure their ideal working environment and focus on the patient, rather than on the equipment and utilities. In addition, having a system that can be easily and quickly adapted to new procedures or room configurations minimizes financial risk for the facility. The U.S. launch of Moduevo is a testament to our ongoing commitment to provide our customers with a one-stop solution for the medical technology, support and services they need to provide patients with the best care possible to achieve optimal outcomes.” •

Healthmark Offers Sterile Wipes for Endoscope Cleaning Healthmark Industries has announced the addition of sterile wipes to its endoscopy product line.

Designed to dry endoscopes and associated equipment per manufacturer’s IFUs after manual high-level disinfection, after removal from an automated endoscope reprocessor (AER), to cover the distal tip of the endoscope during alcohol/air flush, or to dry the basin and connectors of an AER, the 9-inch by 9-inch sterile wipes are manufactured from a synergistic blend of virgin polyester and cellulose that is hydroentangled into a uniform, ultra-durable fabric. These sterile wipes are validated sterile, abrasion resistant and virtually free of particle generation. • For more information, visit www.hmark.com.

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Study Shares Best Practices for Successful UVC Disinfection A recent paper has been published detailing the implementation process of the Benefits of Enhanced Terminal RoomDisinfection (BETR-D) study, the first and only randomized clinical trial on UVC disinfection. The new report, “Implementation Lessons Learned from the Benefits of Enhanced Terminal Room (BETR) Disinfection Study: Process and Perceptions of Enhanced Disinfection with Ultraviolet Disinfection Devices,” was recently published in Infection Control and Hospital Epidemiology. Among the key items discussed are logistic and administrative processes utilized during the trial and lessons learned that are pertinent to future utilization of UVC disinfection devices in other hospitals.

“The study implementation protocols mirror the messaging and program management process that Tru-D currently uses with our hospital partners,” said Alice Brewer, clinical affairs director for Tru-D SmartUVC. “In order for a hospital to implement a successful UVC disinfection program, there must be good communication, a focus on patient safety, compliance tracking and appropriate resource allocation.”

The BETR-D study aimed to disinfect all contact precaution rooms; during the 28-month trial, Tru-D was deployed in 16,220 of 18,411 eligible contact precaution rooms with the median hospital compliance against contact precaution rooms being 89 percent (86 percent-92 percent). In order to achieve this high level of compliance, the authors urge environmental services leadership to work with infection prevention and bed control departments to ensure that enhanced strategies are prioritized in appropriate rooms.

In addition, the authors noted that administrative leaders are often conflicted on whether or not to use UV disinfection due to the need to promptly admit patients waiting in the emergency department or waiting area. The study authors stated, “We believe that this conflict needs to be viewed as a safety issue because enhanced disinfection using UV devices is an evidence-based strategy to improve patient safety.”

The authors further explained that when they tracked the amount of time required to bring a patient to a room labeled as “under pressure” they observed that, “In our experience, this pressure was related more to perception than an actual barrier to use of the UV device … there was always sufficient time to run a standard UV device cycle.” • For more information, visit tru-dpowerofone.com.

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INDUSTRY INSIGHTS

news & notes

Teleflex Announces Peripheral Procedure Snares U.S. Launch Teleflex Inc. has announced 510(k) clearance by the Food and Drug Administration and U.S. commercial launch of new versions of its Expro Elite and Sympro Elite snares for manipulating interventional devices in peripheral procedures.

Both the Expro Elite and Sympro Elite snares represent next-generation versions of the 0.035-inch interventional snares originally launched in the U.S. in 2008 by Vascular Solutions, now a wholly-owned subsidiary of Teleflex Inc. The Expro Elite Snare uses a helical

loop for capture in all directions. The Sympro Elite Snare uses a 90-degree loop that remains coaxial to the vessel lumen for easy capture. Both snare products feature a preassembled, one-piece design that allows rapid deployment through any 0.035-inch compatible lumen. Both the Expro Elite and Sympro Elite snares are available in 5-, 10-, 15-, 25- and 35-millimeter loop diameters for clinical versatility. Both snares are 150-centimeter in length and are packaged one per box.

Both the Expro Elite and Sympro Elite snares are intended for use in the cardiovascular system and hollow viscus to retrieve and/or manipulate objects using minimally-invasive surgical procedures. Manipulation procedures include retrieval and/or repositioning of intravascular foreign objects such as coils, balloons, catheters and/or guidewires within the cardiovascular system. The devices are not intended for use in the coronary arteries or neurovasculature. •

Merivaara Introduces New Operating Table Merivaara has unveiled a versatile operating table for elective procedures. The new, smarter Practico was designed to improve ergonomics with the industry’s widest range of posture possibilities.

“Customers have been asking for a table like this for years,” says Merivaara’s Jyrki Nieminen. “It has been in development for two years and we have received amazing feedback regarding the design, aesthetics and technical specifications.”

Flexible, mobile operating tables are in high demand due to the rise in minimally invasive surgeries. The Practico family of operating tables is modular for a wide variety of surgical procedures. The Practico Max Hi goes up to 45 inches, while the Practico Max Lo goes down to 21.3 inches, making it one of the lowest mobile tables on the market.

The table can handle 617 pounds. When you combine height adjustability with the tilt angle, Trendelenburg angle, and angles for both the back and leg sections, the Practico is impressively adaptable.

The Practico mobile operating table is also smart. A safety sensor in the base cover automatically stops the movement of the table when the leg section touches the base. It also has a simple and easy-to-use hand control with

14 | OR TODAY | APRIL 2018

an intuitive user interface and several memory positions, saving staff from unnecessary hassle.

The user interface is similar to other Merivaara products and can be connected to the Merivaara OpenOR integrated operating room management system. This is part of the Merivaara Fluent concept, which enhances the usability of operating rooms. When surgical staff have the right equipment they can give the best care safely and efficiently. •

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When Quality Matters

Infusion Pump Sales & Support

STERIS Receives Innovative Technology Designation STERIS announced its VERIFY All-In-One Reusable Test Pack and VERIFY Assert Self Contained Biological Indicator have each received a 2017 Innovative Technology designation from Vizient Inc. The designations are based on direct feedback from hospital experts who interacted with the VERIFY All-In-One Reusable Test Pack and VERIFY Assert Self Contained Biological Indicator at the Vizient Innovative Technology Exchange held in Denver, on September 14, 2017.

The VERIFY All-In-One Reusable Test Pack decreases inventory and storage needs by consolidating a single pack for all prevacuum steam air removal and microbial testing needs. One reusable test pack replaces three types of disposable test packs, which reduces waste and can reduce per cycle cost up to 30 percent by using the same test pack up to 200 times.

VERIFY Assert Self Contained Biological Indicator helps facilities keep pace with the busiest OR schedules with the assurance of the industry’s fastest load release, just 40 minutes, for standard cycles. Its innovative glass-free design improves staff safety, reduces cooling time and is quick and easy to use. STERIS’s innovative Process Challenge Device (PCD) is also included with the VERIFY ASSERT SCBI award designation. The PCD is 33 percent smaller than standard test packs and allows for instant confirmation of chemical indicator results upon cycle completion. •

• Flat Rate Repairs • AIV Certified Refurbished Pumps • Replacement Parts

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

Tablet Barrier Sleeve Provides Infection Protection Palmero Healthcare, a Hu-Friedy subsidiary, has introduced the Palmero Tablet Barrier Sleeve to protect portable, sensitive touch screen tablet devices. The single-use disposable sleeve provides infection prevention by mitigating cross-contamination of harmful pathogens.

The easy-to-use Palmero Tablet Barrier Sleeve protects equipment from harmful chemicals by minimizing disinfection requirements. The sleeve fits comfortably over a tablet with or without a case and is compatible with full or mini iPads and tablets.

Made of a material that does not contain latex nor impede touch screen operations, the sleeve has an adhesive on the flap to securely hold the tablet inside. The easy application sleeve accelerates operatory turnover and prevents cross-contamination, minimizing disinfection requirements. • For more information, visit palmerohealth.com.

IMP Offers De Mayo Knee Positioner About 15 years ago, IMP began manufacturing what was to become the company’s “gold standard” in patient positioning for knee surgeries – the De Mayo Knee Positioner, a solution that allows for precise control of flexion, internal and external rotation, and extension of the knee during surgery.

Used in conjunction with the De Mayo Universal Distractor, the De Mayo Knee Positioner is like having “another pair of hands” in the operating room, freeing up OR staff for other time-saving responsibilities.

The De Mayo Knee Positioner is secured to the OR table by the De Mayo Push Button Clamp, an operating table rail clamp that significantly decreases OR set-up time. The clamp is fastened to the operating table simply by squeezing its top and bottom jaws closed on the table’s rail and then locking into place with a twist of the device’s knob. The clamp is quickly and easily removed by pushing the release buttons on the device, lowering the bottom jaw of the clamp.

Manufactured in two different configurations, the De Mayo Push Button Clamp-Standard can be used with the De Mayo Knee Positioner, De Mayo Ankle Distractor or any of the IMP table accessories that require a dual post locking clamp for sterile applications. The De Mayo Pin Locking Push Button Clamp adds additional security when the knob is tightened; the middle jaw locks onto the pins for a more stable construct. •

16 | OR TODAY | APRIL 2018

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INDUSTRY INSIGHTS

news & notes

Study: Leaf System Offers Protection Against Pressure Injuries A new clinical study by researchers at Stanford Health Care looked at whether a wearable patient sensor could improve patient outcomes. The study, “Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study)” is available in the current online issue of International Journal of Nursing Studies. The study found that patients randomized to be treated by Leaf were 73 percent less likely to develop a pressure injury. The optimized care delivery enabled by Leaf

translated into a significant reduction in hospital-acquired pressure injuries. The study can be found through PubMed. The investigator-initiated, prospective, blinded, randomized, controlled trial involved over 1,200 patients and over 100,000 hours of data was analyzed. Patients were randomized to either a treatment or control group. In the treatment group, the Leaf sensor was used to help ensure that patients were repositioned with sufficient frequency and quality. The Leaf sensor continuously

monitors all patient movements and is designed to notify providers if repositioning is required to prevent a pressure injury.

The sensor seamlessly monitors patient position and activity, regardless of whether they are in bed, a chair, or ambulating.

Several studies have shown the Leaf System improves patient turning/ mobility, reduces pressure injury rates, helps nurses prioritize patient care, improve caregiver workflow, and saves hospitals non-reimbursed costs associated with the treatment of pressure injuries. •

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17

COMPANY SHOWCASE Dräger

Company Showcase

räger is a leading international company in the fields of medical and safety technology. Founded in Lübeck in 1889, Dräger has grown into a worldwide, enterprise in its fifth generation as a family-run business. Our North American corporate headquarters is based in Telford, Pennsylvania – just north of Philadelphia, Pennsylvania. Our long-term success is predicated on a value-oriented corporate culture with four central strengths: close collaboration with our customers, the expertise of our employees, continuous innovation and outstanding quality.

D

Dräger, Inc. Director of Marketing, Perioperative Care, North America David Karchner recently shared more details about the company.

Q: What are some advantages that Dräger has over the competition?

Karchner: Anesthesiology has been a driving force behind our company from the very beginning. In close collaboration with our customers, we leverage our extensive experience to develop anesthesia solutions that support a high standard of care and reliability while enabling our customers to realize a financial ROI. Our

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broad operating room portfolio, which includes architectural solutions/medical lights, anesthesia machines, patient monitors, clinical IT, accessories, and service allows our customers to build an ideal operating room environment geared toward their own clinical and financial outcome initiatives.

Q: What are some challenges that Dräger faced last year?

Karchner: Healthcare is quickly transitioning from the traditional “fee-forservice” model to a “population based health” based model. As a leader in the field of anesthesia, Dräger has been asked to collaborate with our customers to not only come up with new methods to drive down costs, but also assist our customers in improving population health, which ultimately has the ability to improve our customer’s financial health more than ever before. It’s a challenge for healthcare in general, but it’s also an incredible opportunity for Dräger to demonstrate our unique capabilities in the operating room.

Q: Can you talk about the company’s core competencies?

Karchner: When you invest in integrated solutions from Dräger, the value you receive from devices and technology is just the beginning. As a true collaborator,

we work closely with our customers to elevate their value through consulting, education, service, and support. Not only can we help improve OR performance, but also ICU and NICU performance as well. We can do so by offering solutions that help improve outcomes, optimize workflow and workspaces, streamline data capture, and support consistent use with common user interfaces and operating philosophies. Ultimately, we believe the solutions we offer can elevate care for patients and help customers realize financial value in entirely new ways.

Q: What product or service are you most excited about right now?

Karchner: The Perseus A500 is the latest anesthesia workstation from Dräger. Designed from the beginning with patient monitoring, clinical IT, service and accessories in mind, its space-saving profile can easily integrate into your OR workspace while helping to improve cable management and streamline hygienic reprocessing.

Consistent with the Dräger anesthesia portfolio, the Perseus A500 is optimized for low- and minimal-flow anesthesia delivery to support a financial ROI for customers. Fresh gas flow efficiency technology (Low Flow Wizard) which has proven to help customers reduce WWW.ORTODAY.COM

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anesthetic agent costs, sample gas recirculation to the breathing system to reduce anesthetic agent waste, and a heated breathing system designed prevent rainout all support consistent low- and minimal-flow anesthesia delivery.

To help customers deliver and maintain a high standard of care, Dräger introduced the TurboVent2 ventilation technology with the Perseus A500. Like our piston ventilation technology on the Apollo and Fabius family anesthesia workstations, the Perseus A500’s TurboVent2 supports ICU-level therapy capabilities - with value-add performance.

CPAP in Man/Spon, Airway Pressure

Release Ventilation (APRV), and an open breathing system design are just some of the therapy value-adds the Perseus A500 can deliver for customers.

While the Perseus A500 is an extremely flexible anesthesia workstation that can be tailored to the unique needs of our customers, consistency with the entire Dräger anesthesia portfolio was a critical point in its design. The user interface, fresh gas controls, vaporizers, and accessories offer a high-level of consistency with the current Dräger anesthesia portfolio which promotes consistent use and device care.

Q: What is on the horizon for the company?

Karchner: In the operating room, you can look for Dräger to continue to deliver innovative anesthesia workstations at the highest of quality. It’s what we’ve done more than 125 years, and we’ve excelled at it. However, as we discussed previously, the business of healthcare is quickly changing from a “fee for service” model to one of “population health.” Look for Dräger to provide new value added offerings and services designed to demonstrate our ability to provide value in “Critical Care Performance,” where Dräger will demonstrate our unique ability to improve our customers’ clinical, operational, and financial performance in the operating room, ICU, and neonatal care areas.

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Q: What are some recent changes to the company?

Karchner: A recent addition to the North American headquarters is the advanced Dräger Healthcare Design Center. The “Design Center” provides our valued customers the ability to look beyond a “medical device purchase” and gives them the opportunity to strategically plan a “work space” that has the opportunity to improve population health in their geographic area.

Q: What is most important about the way Dräger does business?

Karchner: “Technology for Life” is our guiding principle. Wherever our technology is deployed – in clinical settings, industry, mining or emergency services – it protects, supports and saves lives.

We support this guiding principle with a customer intimacy that shapes both our long-term vision and our day-to-day operations, our employees who make a difference in the lives of our customers, responses to human needs with technical innovation, and product and service quality for solutions that our customers rely on to sustain and improve life.

For more information, visit www.draeger.com

APRIL 2018 | OR TODAY |

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INDUSTRY INSIGHTS cs/spd

The Education and Development of CS/SPD Personnel: On-the-Job Training (OJT) is No Longer Enough!

By David Taylor, MSN, RN, CNOR Literature shows that certification can advance the knowledge and expertise of an individual. Having increased awareness and knowledge about one’s job can have a direct impact on patient safety and directly impact the care patients receive. Current practices, a lack of education and training along with engineering factors are what keep central sterile/sterile processing departments (CS/SPD) from being a high-reliability department. In nearly every state your dental hygienist, dog groomer, hair dresser, barber and tattoo artist are required to have a license or, at the very least, complete a training course or pass a competency exam in order to enter the occupation.1 At the time of this publication only four states require CS/SPD technicians be certified, New York, New Jersey, Connecticut and Tennessee. Two states, Massachusetts

and Pennsylvania, have introduced similar legislation in February and June 2017 respectively.2 The knowledge and skills of the CS/SPD team members are critical differentiators, yet many organizations put little emphasis on developing their staff.

In some CS/SPD, only a small subset of core team members can support the instrumentation used in all procedures, which can have a negative effect on service to procedural areas.

Effective perioperative leaders understand the availability of continuous staff education as an essential leadership technique to improve services and care for patients. Education is a key factor in a CS/SPD success, yet far too few health care organizations invest in their employees’ education and training. If you are a registered nurse (RN), organizations have well-defined career paths and opportunities. However, for the typical CS/SPD staff Only a handful of organizations have member these opportunities are far developed clear paths for their CS/SPD and few between.

Often, they receive employees. on-the-job training (OJT) from

22 | OR TODAY | APRIL 2018

the staff member who happens to be present on that particular day or shift.

In addition, the staff members doing the training may have never been to a preceptor training course or have the knowledge necessary to develop educational development plans.

This OJT by whomever is available for that day and the dilution of knowledge from one staff member to another is why so many CS/SPD departments fail. Staff lack the basic skills and the only thing they are told is to hurry and get these instruments turned over.

The first step in developing a staff education program is for the perioperative director to evaluate current team members’ capabilities.

Because there are so few official CS/SPD training programs, and the majority are trained on the job, grouping team members with similar skill levels will help perioperative leaders establish a base line and begin developing a stateof-the-art, evidence-based education program that is efficient and cost-effective. Areas to focus on could include effective onboarding and orientation programs, creating a competency-based training program, WWW.ORTODAY.COM

INDUSTRY INSIGHTS

cs/spd

cross-training initiatives, regularly scheduled in-service and education days, as well as “train-the-trainer” programs that create subject matter experts (SME).

A SME could become part of an educational team that might include lead or service line coordinators.

Advanced transformational learning approaches can help team members take greater individual responsibility for their professional development through certification. An individual who dedicates time to certification can have an influence on their peers to be accountable for their own practice and self-development. A next step in educating team members is to provide preceptor training to individuals who are interested in precepting new employees. Effective preceptors are important because their efforts can cut employee orientation time dramatically, ensure that the same training standards are applied to each employee, and eliminate variables in training. This type of approach allows staff members opportunities to review their current practices and revise them as needed, thus avoiding faulty assumptions and costly errors.3 In addition to investing in educational development programs it is equally important to provide opportunities such as professional conferences and memberships in professional organizations. This can be very effective because it provides incentives to employees who seek to improve their individual practice.

These incentives can also encourage more team members to take an active role in their department and encourages others to become active in professional organizations, seek certification or be the next staff member to attend a regional or national conference.

Health care organizations that have done away with departmentbased educators should strongly WWW.ORTODAY.COM

consider reinvesting in an experienced, master’s-prepared perioperative educator to lead their education, training and development programs. A dedicated educator can be a tremendous asset by bridging the OR and CS/SPD departments and allow team members to master service-related activities. At the very least, the educator can be a resource that reviews the latest guidelines and helps retrain employees who are affected by constant changes in the industry. The cost of this full-time-equivalent can be offset by reducing orientation times and help avoid reimbursement issues related to problems associated with instrumentation cleanliness, preparation and sterilization, which can have a direct impact on procedure times, surgical site infections (SSIs), extended lengths of stay (LOS) and other complications.4 Only a handful of organizations have developed clear paths for their CS/SPD employees. Developing opportunities such as career ladders, certification prep courses and offering reimbursement and financial incentives for those who become certified can create higher reliability that is embraced from all levels of the organization. By creating an environment that promotes education, safety, accountability and collaboration, organizations can mitigate failure and optimize innovation that improves the delivery of safe and effective care, while avoiding the barriers that prevent CS/SPD from achieving high performance.

No longer can hospitals afford to neglect the importance of their central sterile/sterile processing departments. The role it plays is just as important, if not more, than the procedural areas it supports, and today’s perioperative leaders play a critical role in whether CS/SPD is successful or not. Quality is what drives today’s health care business,

and forgoing quantity has huge financial ramifications for the health care industry and the organizations struggling to keep their doors open or provide the same level of services to their communities.

Although sterile processing is often misunderstood, it plays a critical role in today’s health care environment. Hospital administrators and nurse leaders who are responsible for CS/SPD areas must understand the value of proactively managing the day-to-day operations not only to improve performance but to proactively prevent the transmission of dangerous and sometimes deadly diseases, healthcare-acquired infections, or become the latest segment of a national news story. Formal education and the development of an effective educational process is one way to mitigate these risks. Investing in the training of employees while monitoring performance can be the keys needed to open new opportunities while improving quality, safety and financial performance.

References

1. Torpey, E., September 2016, Will I need a license or certification for my job? https://www.bls.gov/ careeroutlook/2016/article/will-i-needa-license-or-certification.htm Accessed January 26, 2018.

2. International Association of Healthcare Central Services Materiel Management https://www.iahcsmm.org/advocacy/ legislative-map.html Accessed October 17, 2017.

3. McNaron ME. Using transformational learning principles to change behavior in the OR. AORN J. 2009;89(5): 851860.

4. Taylor, D.L., Surgical Services Leadership: Insights, Priorities and Tools for Managing Change in the OR, AORN Journal July 2014, VOL 100, NO 1.

APRIL 2018 | OR TODAY |

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INDUSTRY INSIGHTS asca

Health Care Quality: A shared responsibility

By William Prentice egardless of the setting or specialty in which they work, health care providers continue to face a common challenge: measuring and communicating the quality of care they deliver in meaningful ways.

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Done right from start to finish by all involved, quality reporting can drive improvement within a facility, help patients make informed decisions about their own health care and lead to advances in care that affect an entire specialty, practice setting or field of care.

Done wrong, it can lead to confusion, mixed messages and public policies that place roadblocks in the path of progress and even cause or exacerbate the very problems they are trying to solve.

While it is easy to identify the results that health professionals, patients and policymakers want from measuring and reporting quality, finding the tools and techniques needed to achieve those goals is not so simple. Still, health professionals across the country remain committed to that ideal and continue to define and refine programs that collect and share data about the quality of health care available in the U.S.

24 | OR TODAY | APRIL 2018

The ASC community remains at the forefront of these efforts.

ASCs advocated for a national quality reporting program that they could use to help demonstrate the high-quality, high-value care they provide for nearly a decade before the Centers for Medicare & Medicaid Services (CMS) put a program in place in 2012. To help support the development of that national program, in 2006, the ASC community formed the ASC Quality Collaboration (ASC QC). Supporters of the new organization included many well-known ASC management companies, the ASCA Foundation, the Outpatient Ophthalmic Surgery Society and the Association for periOperative Registered Nurses.

Both the Accreditation Association for Ambulatory Health Care and The Joint Commission also backed the group.

One of the ASC QC’s first priorities was to develop quality measures for the outpatient surgery setting that were tied in meaningful ways to both the range of services provided there and the highest standards of care. After careful study and a hand-in-hand effort with the National Quality Forum, which had prior experience developing comparable measures with other providers,

the set of measures the ASC QC developed continues to serve as the basis for Medicare’s ASC Quality Reporting (ASCQR) Program.

In 2018, that program entered its seventh year.

More than 95 percent of Medicare-certified ASCs continue to comply with this program’s reporting requirements each year. Some with experience managing and interpreting quality data consider the ASC quality reporting program to be better targeted to patient interests than some of the quality reporting programs introduced earlier since it contains a higher percentage of outcomes measures. Those measures look directly at patient results, unlike process measures, which focus on the way care is delivered.

Before the national ASCQR program could begin, the ASC QC also began aggregating quality data provided by nearly 1,500 ASCs representing every state except Vermont. That effort continues today, and results remain in line with those produced in the national program.

Both programs find that the incidences of adverse events that occur in ASCs is extremely low.

Currently, comparing the quality data ASCs report with quality data from other outpatient settings WWW.ORTODAY.COM

INDUSTRY INSIGHTS

asca

remains difficult since the measures others report are rarely the same as those that ASCs report. Another complicating factor is that even where some overlap exists, the different processes used to collect the data deliver results that are not comparable. The ASC community continues to advocate for transparency in quality reporting and more standardized measures that will allow patients to compare sites of service more effectively.

Along with these quality reporting programs, work aimed at more fully investigating and demonstrating the quality of outpatient surgical care available to patients today continues in many other areas. For example, we continue to rely on and work with the accrediting bodies to define and evaluate health care quality. We also continue to rely on professional, peer-reviewed research to evaluate current standards of care and uncover trends.

To help build additional data banks that can be used to evaluate and improve quality, the ASC community continues

to participate in and encourage others to participate in voluntary registries like the American Joint Replacement Registry (AJRR). Continuing support for all these efforts is essential if we are going to attain our goals.

Finally, whenever and wherever health care quality is discussed, everyone involved in those discussions – including patients, health professionals, insurers, policymakers and the media – has an obligation to use the health care data that is available to them responsibly. That means taking every possible precaution to maintain patient privacy, of course, but it also means managing and analyzing the available data carefully. Outliers need to be identified for what they are rather than used to inflame the conversation or sensationalize a story.

Data needs to be collected and analyzed carefully, and context needs to be provided. Lessons learned need to be tested, reevaluated and refined.

When it comes to measuring, reporting and talking about health care quality, the health care community’s work has just begun.

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APRIL 2018 | OR TODAY |

25

INDUSTRY INSIGHTS webinar

Strong Start to 2018 Webinars Staff report he first OR Today webinar of 2018 was a timely topic.

Ken Perez, vice president of health care policy at Omnicell Inc., presented “Health Policy Changes Under the Trump Administration.”

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He discussed the changing sentiments about health policy changes, and the current political battleground in Washington, D.C. He also offered a review of 2017 as well as political realities and renewed concerns about health care.

Attendees learned about a framework that predicts the most likely health changes under the Trump administration as well as a look at what health policies are least likely to change. Perez also discussed the implications for health care providers of likely health policy changes.

About 100 perioperative professionals attended the informative webinar and they praised the presentation in postwebinar surveys. “’Health Policy Changes Under the Trump Administration was very insightful and provided me with a better understanding of how the legislature works to approve/repeal health care acts.

I gleaned information about other states and ways to succeed in decreasing costs that my state could benefit from,” shared K. Steele, Manager Surgical Services.

“Very good webinar, I follow the news but this was a nice concise description of where we are as a country at the present,” said E. Fraser, Senior Systems Analyst.

“Excellent webinar and I liked that it

26 | OR TODAY | APRIL 2018

February 15 as Thomas Overbey, BS, CCSVP, Director of Marketing for Ultra Clean Systems presented “A Cavitating Experience! Ultrasonic Cavitation Webinar for More Than SPD Professionals.”

This multifaceted webinar was a reflection of the audience who work in various health care disciplines ranging from nursing to serving in the OR to sterile processing and infection control.

Surgical instruments can be complex devices and they continue to increase in complexity. In many cases, ultrasonic cleaning is indicated by the instructions for use (IFUs). As a result, there is confusion in the industry as to when the cleaning process actually begins and how ultrasonic cleaning is used correctly for maximum outcomes.

This visually informative webinar provided a diverse and cohesive set of information through still-frame animation and clear, easy-to“This was a great presentation understand images as it illustrated how and that gave clarity and simplified what why ultrasonic cavitation is so important. health care has gone through and More than a hundred health educated us moving forward.” care professionals attended the live – S. Knutson presentation and more have viewed it online on the OR Today website and on “This was the first OR Today webinar YouTube. that I have participated in. I will definiteAttendees shared positive feedback ly be back for more,” exclaimed L. Rath, regarding the webinar and the OR Today Staff Nurse. series in a post-webinar survey. Some of The OR Today webinar series conthe most experienced professionals plan tinued to deliver valuable content on

correlated the changes over the years and past few months,” said T. Symonds, OR Business Manager.

“This was a great webinar – very interesting, real time topic and great information. We need more people like Ken to speak to our governmental lawmakers,” said T. Ralls, Clinical Improvement Patient Safety Business Partner.

“This was a great presentation that gave clarity and simplified what health care has gone through and educated us moving forward,” shared S. Knutson, Surgical Services Manager.

“I agree with Ken’s summary that we are in a period of uncertainty, we need to reduce spending, embrace value base care and hold tight for the ride as everyone muddles through this complex state of health care,” said L. Mondary, Administrator.

WWW.ORTODAY.COM

INDUSTRY INSIGHTS

webinar

to share the recorded presentation with their staffs.

“The OR Today webinar by Ultra Clean Systems was good for all levels of experience in the SPD. I have worked in sterile processing for 26 years and this presentation reinforced some of the things I knew and provided me new knowledge on updated process requirements. I would love to give this in-service to all my staff,” L. Borgmann, Sterile Processing Supervisor, said.

“The demonstration of the sound waves converted to energy for cleaning was very helpful. … I have worked in surgery and/or SPD for almost 40 years and this was a great source of information for new as well as seasoned staff,” wrote K. Johnston, Nurse Educator SPD. “This was a very informative webinar. The presenter had excel-

lent knowledge of the material and was interesting to listen to,” shared S. Petruzzi, Nurse Manager.

“I was able to walk away from the webinar with more knowledge and helpful tips after this. I highly recommend this to any health teams,” shared L. Grant Jr., Sterile Processing.

“Thank you for the very interesting and informative webinar on ultrasonic cleaning. It was captivating,” L. Rogala, CRCST, said in a survey.

“The webinars offered by OR Today are always time well spent! Thank you,” said A. Poe, Clinical Nurse Specialist.

“OR Today’s webinar was superior to those I have attended in the past. The material presented was cohesive to all areas of the OR, not only sterile processing. I would highly recommend ANYONE who works in the OR to check out OR Today’s webinars,” said S. Hanlon, CRCST.

“OR Today’s webinar series are insightful and thought provoking – a must for all in Periop Management,” said T. Sanders, Manager Surgical Services.

“I really like the OR Today webinar series. Not all of the webinars may pertain to my position, but they are all relevant to the nature of the perioperative arena today. I like that I can listen to them and always learn something new.

I work in a freestanding ASC and wear many hats, so listening to the different webinars keeps me abreast of what is going on in other areas of perioperative care such SPD, PACU, employee health, etc.,” said S. White, RN, CNOR. For information about the webinar series, including recordings of previous presentations and a calendar of upcoming webinars, visit ORToday.com and click on the “Webinars” tab.

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APRIL 2018 | OR TODAY |

27

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 28 | OR TODAY | APRIL 2018

LOCAL CASES

Is it acceptable to have patients that are having straight locals wear their street clothes into the OR? Also, some surgeons are requesting that the patients only have BP and pulse ox, not EKG monitoring. Is this acceptable?

A: Quick turnovers are always an issue, but

unfortunately anyone entering the OR needs to be in proper OR attire, including the patient.

The patient needs to be clean, in a clean patient gown (facility socks), head covering and clean linen.

Page 111 (I.d.) in the 2018 AORN Guidelines states: “That anyone entering the OR semirestricted or restricted, including police officers, parents, biomedical engineers, should don either clean scrub attire, or a single use jumpsuit, even when entering for a brief period of time.”

A: If you do other cases in that OR that are at risk

for SSI then you cannot allow street clothes.

We don’t do EKG monitoring on straight locals.

A: As for attire to be worn within the surgical

suite, I agree that anyone entering the OR needs to be in proper OR attire. As for the question regarding the appropriateness of EKG monitoring, I would direct any nursing clinician to review Recommendation II, from AORN’s 2017 Guideline for Care of the Patient Receiving Local Anesthesia, page 620, regarding determining need for EKG monitoring.

SKIN PREP

Does anyone have any other alternatives to a skin prep solution or cleanser if 3.3% Choroxlenol (ScrubCare) by Care Fusion is not available? This product is no longer manufactured. If the patient is allergic to betadine, CHG and the cleanser is needed for a facial, perineal or vaginal area, what are your institutions using? Some suggestions were J&J baby shampoo, diluted hydrogen peroxide with a water rinse and bar soap. Many institutions no longer have bar soap.

A: Below is from an abstract for a study regarding use of baby shampoo as a vaginal prep solution.

Bar soap should not be an option, as some contain Triclosan.

“CONCLUSION: Baby shampoo should be studied as an alternative to povidone-iodine WWW.ORTODAY.COM

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(PI) because it is a nonirritating, inexpensive mild detergent. This preliminary study suggests that baby shampoo is as effective as PI in preventing postoperative infection.”

A: More studies should be conducted.

A: Agreed. There are a few studies

out there, and we do have baby shampoo on formulary, however, it is off-label use according to J&J.”

ASK YOUR QUESTION AT THEORNATION.COM

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29

“ you ’ re getting sleepy, and also very, very organized.”

Key Surgical Breakaway Tags provide extra security so your sterile processing department doesn’t spiral into a state of disarray. They cinch close and provide a tamper resistant lock that must be cut or broken to open. Plus, they come in bright colors for quick identification. Place your order today.

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or visit keysurgical.com

IN THE OR

market analysis

Outsourcing to Impact Sterile Processing Market Staff report

o ensure better compliance with infection control standards and top-notch management of sophisticated surgical instruments, United States (U.S.) and Western Europe-based health care centers are increasingly outsourcing central sterile supply department (CSSD), also known as sterile processing department (SPD), functions, according to a news release from Frost & Sullivan.

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“Until 2022, third-party sterilization service vendors will focus on becoming end-to-end solution providers, covering CSSD layout design, tracking and managing workflow, cleaning, sterilization and logistics services,” according to Frost & Sullivan. “This will reshape the competitive landscape as original equipment manufacturers (OEMs) will race to include value-added services, such as equipment repair, inventory management and CSSD integration in their portfolio.”

“Market players, especially sterilization and disinfection equipment manufacturers struggling with diminishing sales, are adopting aggressive strategies to bolster their service offerings and expand operations locally and internationally,” said WWW.ORTODAY.COM

Frost & Sullivan Transformational Health Senior Research Analyst Anuj Agarwal.

“These measures include acquiring rivals to gain market share and joint ventures with local players to enter new markets.

Bigger players will look at value-chain integrations to gain broader strategic advantage.”

“Third-party Sterilization Services for Care Providers in the U.S. and Western Europe, Forecast to 2022,” an analysis from Frost & Sullivan’s Transformational Health Growth Partnership Service program, explores service models in the U.S. and Western European markets, and factors driving OEMs to embrace a service-based model over the traditional product-centric approach. The research also details major market trends such as commoditization of standalone sterilization equipment business, operating room (OR) and CSSD integration, and replacement of managed services by integrated CSSD or OR solutions.

By 2022 up to 45 percent of care providers in the U.S., United Kingdom, Italy, Germany and France will opt for third-party sterilization services for CSSD management, according to Frost & Sullivan. The surgical department’s lack of awareness about the quality of services is hindering this adoption. To overcome

this, service providers must build credibility and brand value.

“Third-party sterilization services are the first step towards better infection control and potentially open further avenues of growth for market participants by putting them in direct contact with key decision makers in care settings,” observed Transformational Health Industry Principal Sowmya Rajagopalan.

Grand View Research, however, predicts growth in the equipment market over the next several years.

“The global sterilization equipment market size was valued at $3.9 billion in 2015. The increasing number of surgical procedures and aging populating are the major factors expected to propel the growth,” according to Grand View Research. “In addition, the rise in the incidence of chronic diseases and various initiatives taken by the government to ensure adoption of essential sterilization standards in hospitals and research centers is expected to drive the growth of the sterilization equipment industry during the forecast period (2014-2025).

Currently, stringent medical safety and infection control norms are increasing public awareness of the global population resulting in shorter hospital stays and lesser health care costs.”

APRIL 2018 | OR TODAY |

31

IN THE OR

product focus

Cygnus

Airtime Instrument Channel Dryer Properly dried channels reduce the risk of infection. Studies indicate there is a strong correlation between moisture and microbe colonization within flexible endoscopes. The Airtime Instrument Channel Dryer uses filtered air to dry the air/water and suction channels after automated reprocessing. It ensures scopes are not stored or put into immediate use with wet channels. Airtime uses HEPA filtered air to dry the air/water, suction and auxiliary water channels after automated reprocessing.

Also available with a medical grade air option.

Features include: • Uses two independent pumps and timers that will dry two scopes simultaneously.

• Air pressure will not drop when you begin drying a second scope.

• Airtime’s dual screen allows for two scopes to be dried with independent start and stop times.

• Restricted channel sensors will immediately shutoff the Airtime pump and alert the user of a potentially clogged channel.

• Available options include; IV pole mount, wall mount or on a table stand. •

32 | OR TODAY | APRIL 2018

WWW.ORTODAY.COM

IN THE OR

product focus

Microsystems SPM

With HL7, bi-directional integration with Epic and other leading EMRs all your needs can be satisfied every day for every surgical case. By keeping Set Names and Inventories in sync confusion is eliminated and conflict scheduling optimized. By receiving the “Sets Required for Cases” detail all SPD resources remain focused on specific OR demand whether trays are owned, loaned or consigned. By documenting “Sets Used on Cases” the interface can be further leveraged to ensure traceability of uniquely identified surgical assets to the patient through the CASE ID. • For more information, visit www.mmmicrosystems.com.

WWW.ORTODAY.COM

APRIL 2018 | OR TODAY |

33

IN THE OR

product focus

3M

Attest Vaporized Hydrogen Peroxide Sterilization Assurance Product Portfolio 3M offers a comprehensive vaporized hydrogen peroxide (VH202) sterilization monitoring package.

Together the 3M Attest Rapid Readout Biological Indicator (BI) System, 3M Comply Hydrogen Peroxide Indicator Tape 1228 and 3M Comply Hydrogen Peroxide Chemical Indicator 1248 make load monitoring possible, while helping to streamline workflow. The Attest Rapid Readout BI System provides a readout in just 24 minutes, and the chemical indicator and indicator tapes are easy to use, applying the same color change system from blue to pink for quick reference. The full package improves efficiencies and ensures patients receive a high standard of care. •

CARDINAL HEALTH

Nitrile Decontamination Exam Gloves With a full finger textured grip, 16-inch extended cuff, and fingertip thickness of 11 mil., Cardinal Health’s new Nitrile Decontamination exam gloves give the SPD team members protection up to their elbows. •

34 | OR TODAY | APRIL 2018

WWW.ORTODAY.COM

IN THE OR

product focus

Certol

ProEZ Foam Avoid scrutiny from hospital auditors and increase compliance at point-ofuse with ProEZ foam, a ready-to-use neutral pH instrument pre-cleaning spray. It will never dry hard and contains a blend of four enzymes, surfactants and anti-corrosives to quickly break down surgical soils. Offsite clinics, orthopedic, emergency, labor/delivery and central processing can benefit from ProEZ foam, tested (ASTM standard D7225) to clean and protect instrumentation for up to 72 hours. • For more information, visit www.Certol.com/ProEZFoam

WWW.ORTODAY.COM

Key Surgical

Lumen Guard Cleaning Brush Surgical instrument cleaning just got a little smoother. Introducing the Lumen Guard Cleaning Brush from Key Surgical. This new line of channel cleaning brushes features a smooth, protective tip (traditional exposed wire at the end of the brush is transformed through Z-Tip technology) and rigid, antimicrobial nylon bristles help with effective removal of debris during decontamination. Available diameters of .05” to 1” and lengths of 6” to 24”.

The Lumen Guard Cleaning Brushes are sold either 2/pkg or 50/pkg and are available on www.keysurgical.com. •

APRIL 2018 | OR TODAY |

35

IN THE OR

product focus

Steelco

DS1000 FAST Instrument Washer The Steelco DS1000 FAST Instrument Washer helps achieve higher productivity levels. It features a powerful washing and disinfection system, green technology and cutting-edge automation options.

oneSOURCE

Document Management Service If a facility doesn’t sterilize according to manufactures’ validated instructions for use documents (IFUs), there’s risk for higher infection rates, costly citations and damaging publicity. oneSOURCE makes it affordable and easy for a facility to follow IFUs as required by CMS, Joint Commission and AAAHC accreditation. Our online surgical, equipment and biomed databases put thousands of validated IFUs and PM documents at your fingertips, improving processing efficiency, patient safety and making reimbursements more reliable. •

Productivity features include: • Fast programs • Color touchscreen with interface for track and tracing software • Optional back-up electrical heating to allow completion of cycles without house steam • Large capacity chamber for surgical trays up to 32-inches long • Pre-heating tanks eliminating machine idle times for water heating • Flow meter controlled detergent injection, assuring precise dosing also for highconcentrate products Quality features include: • Triple-stage water filtration system protects washing circuit • Validatable and precise monitoring of all process relevant parameters • Automatic rack coding guarantees no lubricant use with implant loads •

For more information, visit onesourcedocs.com

36 | OR TODAY | APRIL 2018

WWW.ORTODAY.COM

IN THE OR

Medline

product focus

SteriSet Sterilization Container With over 20 years of history behind it, Medline’s SteriSet sterilization container is the only completely reusable container on the market. Its innovative design eliminates disposable filters and locks/arrows required with other container systems. Three patented features are available on all containers, including a reusable, pressure activated valve that opens and closes during steam pre-vacuum cycles, Thermoloc container locking technology that ensures hygienic security and condensation drains. These features are all covered by a lifetime warranty. Additionally, SteriSet’s color coding capabilities help promote best-practice standards and enhance efficiency. • For information, visit medline.com/ pages/central-sterile.

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Tuttnauer

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40 | OR TODAY | APRIL 2018

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continuing education

CE463

Anticoagulant Overdoses Prompt Joint Commission to Issue National Patient Safety Goals

by Jennifer L. Gibson, PharmD

nticoagulants are some of the most common medications associated with adverse drug events (ADEs) in hospitalized patients.

These ADEs are associated with increased mortality and increased healthcare costs. Many anticoagulant-related ADEs are the result of a medication error, which means that they are potentially preventable.1

A

In the last decade, anticoagulant errors have been the subject of public attention and scrutiny. In 2007, the newborn twins of actor Dennis Quaid received 1,000 times the prescribed dose of the anticoagulation medication heparin. A third newborn in the same California hospital also received an overdose of heparin. Luckily, none of the newborns experienced lasting effects.2 In 2006, a pharmacy technician in Indiana mistakenly stocked 10,000 units/mL vials of heparin in a medication drawer in the newborn nursery where 10 units/mL vials were normally stored. Three newborns received erroneous doses and died.

These events helped shape safety systems and quality improvement programs specific to anticoagulation therapy.1-3

Safety in Systems Nurses provide direct patient care and spend a significant amount of time with WWW.ORTODAY.COM

patients, so it is fitting that patient safety has long been considered the nurse’s responsibility. However, evidence is growing that supports the importance of safe systems, and organizations such as The Joint Commission and Quality and Safety Education for Nurses are helping all healthcare providers develop and participate in systems for safer care.4 In addition, the Institute for Safe Medication Practices newsletters highlight incidents throughout the country to bring attention to medication errors. These newsletters provide nurses, other healthcare professionals, and quality improvement personnel the information needed to examine their practices and make improvements in patient safety initiatives.

A key part of this effort is the annual updating of The Joint Commission’s National Patient Safety Goals (NPSGs).

The NPSGs are determined after a review of sentinel events tracked nationally. In 2008, one update prompted the expansion of NPSG 3 (improve the safety of using medications) to include reducing the likelihood of patient harm associated with anticoagulation therapy.

This goal continued to be emphasized across multiple care setting in the 2016 and 2017 NPSGs.5 Nurses must be knowledgeable about anticoagulants to ensure safe practice and improve patient safety.

Anticoagulants are used to prevent or treat venous thromboembolism (VTE), which includes deep vein thrombosis

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 anticoagulant continuing education program is to inform nurses of current care practices for patients on anticoagulation therapy in the hospital. After studying the information presented here, you will be able to: •

Identify the most common anticoagulants for hospital patients

•

Describe critical aspects of nursing care when monitoring anticoagulants

•

Discuss the critical elements of patient teaching regarding anticoagulation therapy

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continuing education (DVT) and pulmonary emboli (PE).

(Anticoagulants prevent new clots from forming and prevent existing clots from getting bigger; they do not dissolve existing clots.)

Anticoagulants are high-alert medications that pose a risk of injury or death if not administered correctly. Mistakes with anticoagulant administration do not necessarily occur more often than with other drugs, but the consequences are more devastating. Since anticoagulants are high-alert medications, many institutions require double-checks by two RNs to help prevent a medication error.5 Most hospital patients receive anticoagulants because of the risk of DVT that results from immobility, although most patients have more than one risk factor for VTE. General risk factors include age older than 60, obesity, smoking, a history of DVT, acute illness, indwelling central venous catheters, surgery, estrogen therapy, cancer and cancer therapy, inflammatory conditions, acute infectious processes, heart failure, chronic lung disease, stroke, and varicose veins.6 A DVT places patients at high risk for PE. A PE occurs when a blood clot (i.e., a DVT) travels to one of the pulmonary arteries; the clot blocks blood flow to the lungs and is, therefore, life-threatening. If not treated, a PE is associated with a high mortality rate.6 A DVT also increases costs to the patient and the healthcare system: If a patient experiences a DVT, he or she will likely have an increased hospital stay and undergo additional diagnostic testing, such as blood tests, ultrasound evaluations, X-rays, or CT or MRI scans.6 Anticoagulation therapy is the primary method for treating and preventing DVT. Heparin products, which include unfractionated heparin and low-molecularweight heparin (LMWH), are the most common medications used to prevent and treat VTE in hospitals, and they are associated with a significant reduction in the risk of DVT and PE.6 Each medication targets a different area of the coagulation cascade to prevent the de-

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velopment of thrombi by preventing the conversion of fibrinogen to fibrin. However, these medications do not dissolve existing thrombi. If a patient requires ongoing anticoagulation after discharge, warfarin (Coumadin, Jantoven) is the most common oral agent, but new, novel oral anticoagulants are increasingly used in practice as alternatives to warfarin.6

Unfractionated Heparin Patients receive unfractionated heparin subcutaneously for DVT prophylaxis.

Hospital patients with risk factors for DVT will receive two or three times daily dosing, depending on the condition and risk factors.6 When administering heparin, inject it into the subcutaneous tissue of the abdomen and rotate sites for each injection. Do not aspirate or massage the injection site. Because of the risk of hematoma, unfractionated heparin should not be given IM. Assess the subcutaneous injection sites for hematomas, ecchymosis, and inflammation.

IV infusion of unfractionated heparin is used to treat DVT and prevent embolization related to atrial fibrillation, specifically to prevent thrombi in patients in A-fib for more than 48 hours. The American College of Chest Physicians (ACCP) guidelines recommend weight-based dosing of heparin for VTE prevention: start with a bolus of 80 units/kg followed by a continuous infusion of 18 units/kg/hr for VTE.6 For patients with cardiac or stroke-related factors, a bolus of 70 units/kg followed by a continuous infusion of 15 units/kg/ hr is recommended.6 If weight-adjusted dosing is not preferred, a bolus of 5,000 units followed by a continuous infusion of 1,000 units/hour may be given.6 Heparin infusion is adjusted typically on the basis of a standardized heparin dosing protocol.6 These dosing protocols provide consistency in dosing regimens and guide prescribers to order the most appropriate dose to achieve a desired therapeutic range of anticoagulation. To ensure safety, many hospitals adhere to the best

practice of having two RNs double-check the IV bolus and dosing of continuous IV heparin. An IV pump must be used to administer continuous IV heparin.5

In Case of Overdose Protamine sulfate (1% solution) is the antidote for unfractionated heparin. When bleeding requires the reversal of heparin, protamine sulfate (no more than 50 mg) should be slowly administered over 10 minutes.

Each milligram of protamine sulfate neutralizes about 100 units of heparin.7 However, because of heparin’s short half-life (one to two hours), an overdose can often be treated by simply stopping the heparin.7 (Note that protamine sulfate may put patients who are allergic to NPH, a protamine-containing insulin, at an increased risk of developing a serious adverse reaction, such as anaphylaxis.8) Baseline lab studies such as hemoglobin, hematocrit, activated partial thromboplastin time (aPTT), and platelet count should be obtained before starting heparin therapy.9 Platelet counts should be monitored every two or three days throughout therapy.9 If the platelet count drops by 50% between days five and 14 of heparin therapy being initiated, even if the heparin therapy has been discontinued, heparin-induced thrombocytopenia should be suspected.9 (Normal platelet counts in adults are 150,000/mcL to 400,000/ mcL.) If HIT is suspected or confirmed through laboratory studies of platelet count or detection of antibodies against heparin complexes, the ACCP guidelines recommend the use of a nonheparin anticoagulant, such as danaparoid (Orgaran), lepirudin (Refludan), argatroban, fondaparinux (Arixtra), or bivalirudin (Angiomax).9 HIT can occur at any time a patient is re-exposed to any form of heparin. Therefore, HIT should be a prominent incident WWW.ORTODAY.COM

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continuing education

in the patient’s history, and heparin should be listed as an allergy.

Heparin’s anticoagulative effect can be monitored by aPTT values or activated clotting times (ACT).

A normal aPTT is 24 to 36 seconds, and a therapeutic range for aPTT is 1.5 to 2.5 times a patient’s baseline aPTT.7,10 A normal ACT value is 80 to 135 seconds, and a therapeutic ACT value for a patient on heparin is three minutes.11 In general, aPTT values are used for monitoring in most instances, but ACT levels are used when removing a catheter after a vascular procedure, such as a cardiac catheterization. When intermittent IV heparin therapy is used, an aPTT level may be drawn 30 minutes before each dose during initial therapy and then periodically.10 For continuous IV heparin, monitor the aPTT every six hours during early therapy and adjust the dose accordingly.10 Once the levels have stabilized within the therapeutic range, monitoring can be less frequent. For subcutaneous administration, the aPTT should be drawn four to six hours after injection.10 The frequency of drawing aPTT levels and therapeutic values will depend on hospital protocols and will vary depending on the indication for heparin (e.g., if heparin is ordered for the treatment of acute myocardial infarction [MI], ischemic stroke, or PE).11

Low-Molecular-Weight Heparin LMWH, such as enoxaparin (Lovenox), dalteparin (Fragmin), and tinzaparin (Innohep), can be used for DVT prophylaxis, DVT treatment, and treatment of some cardiac conditions, including acute coronary syndromes, such as unstable angina and non-ST segment elevation MI. Enoxaparin is one of the most common LMWHs prescribed in acute care.12 Usually, LMWH is administered subcutaneously. For DVT prophylaxis, LMWH has a longer half-life than WWW.ORTODAY.COM

unfractionated heparin, so it usually requires fewer injections.9 Dosing of LMWH for DVT prophylaxis is not weight based, and monitoring of the aPTT is not required. (Dosing of LMWH is weight based in other conditions, such as DVT treatment, unstable angina, and non-ST segment elevation MI.) However, the patient is still at risk for HIT. When administering subcutaneous LMWH, do not expel the air bubble from the prefilled syringe before injecting the medication, because of potential medication loss. In all other aspects, subcutaneous administration of LMWH can follow the guidelines as those for unfractionated heparin.

The Antidote As for heparin, the antidote for LMWH is protamine sulfate. The following overdose guidelines can be used for enoxaparin, which has a halflife of three to six hours: treat with a slow injection (over 10 minutes) of protamine sulfate (1% solution); give 1 mg IV for every 1 mg enoxaparin if enoxaparin was administered in the previous eight hours. An infusion of 0.5 mg protamine sulfate per 1 mg of enoxaparin may be administered if enoxaparin was administered more than eight hours previously.13 A second infusion of 0.5 mg protamine sulfate per 1 mg of enoxaparin may be administered if the aPTT measured two to four hours after the first infusion remains prolonged. After 12 hours from the time of enoxaparin injection, protamine sulfate may not be required.10 Before starting any LMWH therapy, baseline laboratory studies should be collected. These include a complete blood count; platelet count (a baseline is needed in the event of HIT); prothrombin time (PT)/international normalized ratio (INR); aPTT (e.g., if the patient has a pre-existing coagulopathy); and creatinine clearance. Patients with poor renal function (a creatinine clearance less than 30 mL/minute)

must receive lower dosages of LMWH or an alternative anticoagulant because the medication is partially excreted by the kidneys.6 (Normal values for creatinine clearance for men are 95 to 135 mL/minute; normal values for women are 85 to 125 mL/minute.)

Because LMWH acts on a different part of the coagulation cascade than heparin, a patient’s aPTT and ACT are not monitored routinely during LMWH therapy.13 During LMWH therapy, monitor the patient’s platelet count and hematocrit. If an unexplained thrombocytopenia occurs, notify the healthcare team and monitor the platelet count closely. Similarly, if a patient’s hematocrit suddenly drops, assess the patient for potential bleeding sites and hold the medication.10

Oral Anticoagulants: Vitamin K Antagonists and Direct Oral Anticoagulants Warfarin (Coumadin, Jantoven) is a vitamin K antagonist and the most common oral anticoagulant. Predominantly used as an outpatient anticoagulant, it is prescribed to prevent and treat thrombi.

It is often used with patients who have A-fib, a cardiac pacemaker, or heart valve replacements.13 Warfarin interferes with the hepatic synthesis of vitamin K-dependent clotting factors and is monitored by following the PT level.13 Because of variation among reagents used in laboratories, PT results are reported as an INR — an international standardized ratio for PT that is used to monitor long-term warfarin therapy.13 A normal INR for a person not receiving anticoagulant therapy is 0.9 to 1.1. The therapeutic range for INR for thromboprophylaxis is 2 to 3.6 For patients receiving warfarin for A-fib, the ACCP recommends an INR between 2 and 3 with a goal INR of 2.5.6 Dosing of warfarin for patients with prosthetic cardiac valves depends on the type of valve and location of the valve. Target INR values for these patients are between 2.5 and 3.5, with a goal INR of 3.14 Normal APRIL 2018 | OR TODAY |

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continuing education adult doses of warfarin range from 2.5 mg/day to 10 mg/day and are adjusted on the basis of the INR. All doses of warfarin will be individualized and could fall outside of this normal range.10 Possible adverse effects of warfarin include hemorrhage, GI bleeding, and a rarely occurring anticoagulant-induced skin necrosis.13 Lesions associated with skin necrosis generally appear within the third to the eighth day of starting warfarin therapy.13 The lesions generally appear on the breast, buttock, abdomen, or thigh. Pain is often the first symptom, and petechiae progress to hemorrhagic bullae (large vesicles filled with blood), hemorrhagic infarction (a clot that compromises circulation in the area), and full-blown necrotic eschar.15 The best way to prevent warfarininduced skin necrosis is to identify at-risk populations (primarily obese, middle-age women). Excessive anticoagulation may be controlled by discontinuing warfarin, or, if anticoagulation needs to be immediately reversed, by administering phytonadione (vitamin K). For significant bleeding, 10 mg of parenteral vitamin K should be administered.13 In case of severe hemorrhage, clotting factors can be returned to normal by administering fresh whole blood or fresh frozen plasma in addition to vitamin K.13 Food interactions with warfarin are numerous, and they are important to review with patients. Foods that contain vitamin K, including asparagus, beans, broccoli, cabbage, cheese, fish, milk, rice, spinach, and yogurt, reduce warfarin’s anticoagulant effect.16 Another important dietary interaction occurs with alcohol: Chronic use and binge drinking can alter the therapeutic levels of warfarin.16 Interactions can occur between a variety of medications and warfarin, with some reducing clotting factors

44 | OR TODAY | APRIL 2018

and interfering with vitamin K metabolism. The following examples of drug interactions are only a small selection of potentially significant medication problems related to warfarin; patients should be encouraged to understand the high risk for interactions and regularly review all medications, both prescription and OTC, with their care provider.

Medications that reduce the anticoagulant effect of warfarin include phenobarbital (Luminal), nitroglycerin (Nitro-Bid), digoxin, and carbamazepine (Tegretol). Nicotine can have a reductive effect on warfarin. Medications that can potentiate the effect of anticoagulants include many antibiotics, including several aminoglycosides, penicillins, and cephalosporins; all nonsteroidal antiinflammatory drugs (NSAIDs); acetaminophen (Tylenol); glucagon (GlucaGen); cimetidine (Tagamet); omeprazole (Prilosec); fluconazole (Diflucan); and medications that contain aspirin (e.g., Excedrin, Bufferin).16 Many herbal products also interact with warfarin: St. John’s wort, garlic, ginseng, and green tea may reduce the efficacy of warfarin, while ginkgo may contribute to increased bleeding.16 Carefully review all medications and herbal supplements taken by a patient on warfarin to assess for deleterious interactions, and educate patients on the importance of not adding or stopping new medications while taking warfarin without the support of the care provider.16 A patient who has been anticoagulated in the hospital with heparin or LMWH and needs to remain on an anticoagulant after discharge may be treated with concomitant heparin and warfarin therapy. In these patients, heparin or LMWH “bridging” to warfarin therapy is recommended.6 To maintain continuous anticoagulation, it’s advisable to

continue full-dose heparin therapy while overlapping with four or five days of warfarin. When warfarin has produced the desired PT/INR, heparin may be discontinued.

As mentioned, the blood test for monitoring warfarin’s anticoagulation effects is the PT/INR. Patients new to warfarin therapy may have their PT/INR level checked daily.

Once patients reach the therapeutic range appropriate for their anticoagulation needs, the PT/INR can be checked at longer intervals (up to every 12 weeks).6 Because of the many outside variables that can affect warfarin’s anticoagulation, patients must have their PT/INR drawn on a regular schedule.16 Direct oral anticoagulants (DOACs) are newcomers to the therapeutic armamentarium and offer alternatives to warfarin. A direct thrombin inhibitor, dabigatran (Pradaxa), is an oral anticoagulant approved by the U.S. Food and Drug Administration for stroke prevention in patients with A-fib not caused by a heart valve problem.13 This drug does not require frequent blood tests to monitor its anticoagulant effects, making it a desirable alternative for patients not wanting the inconvenience of the frequent monitoring required with warfarin.13 Upon initiation of dabigatran, renal function is assessed, and drug doses are based on the creatinine clearance. Renal function should be monitored periodically over the course of treatment.13 Rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa) are direct factor Xa inhibitors.

These agents, along with dabigatran, have been shown to be at least as effective as warfarin in many patients. They also have lower risks of major and clinically relevant bleeding than warfarin.17 Routine monitoring of anticoagulant levels is not WWW.ORTODAY.COM

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required for DOACs, partly because of the very predictable pharmacokinetics and pharmacodynamics of these agents and partly because of the small number of drug and food interactions with these agents compared with warfarin. However, some clinicians desire a laboratory parameter to assess the anticoagulation state of patients and predict the risk of bleeding. At therapeutic doses of DOACs, PT and aPTT are prolonged, but the ranges are small and variable, so they are not recommended for routine monitoring.17 The place of DOACs in anticoagulation is still being determined.

Anti-Anticoagulation for Oral Anticoagulants Bleeding is a potential complication of all anticoagulants, and concerns about the reversal of a drug’s anticoagulant effects could be a barrier to use. Any assessment finding that indicates a patient is at increased risk for bleeding is a possible contraindication to anticoagulation therapy. The healthcare team should assess whether the patient has active bleeding (e.g., IV bleed, trauma, or intracranial hemorrhage) or a history of HIT. If the patient is thrombocytopenic (platelet count less than 100,000/mcL), pharmacologic approaches to anticoagulation are too dangerous. A thorough review of the patient’s medications is needed with a focus on any oral anticoagulants or platelet inhibitors (e.g., NSAIDs, clopidogrel [Plavix], and salicylates).16 Mixing two anticoagulants or taking platelet inhibitors with anticoagulants is not advised. Because of the renal excretion of LMWH, the patient’s creatinine clearance must be within the normal limits before initiating therapy.

Any history of hemorrhage must be reviewed carefully to assess the WWW.ORTODAY.COM

patient’s risk of bleeding. Also, determine if the patient will go to surgery in the immediate future: Patients awaiting surgery are not good candidates for oral anticoagulation therapy. These patients may benefit from a continuous infusion of heparin, which can be discontinued easily before surgery. Likewise, patients who already receive oral anticoagulation therapy and will undergo surgery or a dental procedure may need an alternative regimen to manage VTE risk or need a brief discontinuation of oral therapy.

Caution should be exercised when using anticoagulants with a patient whose history includes bleeding disorders, GI bleeds, or hemorrhagic strokes. 7 Contraindications to warfarin are similar to those for heparin and LMWH. Any patient who demonstrates bleeding abnormalities is not a good candidate for warfarin. In addition, women who are or may become pregnant should not take warfarin, because it passes through the placenta and may cause fatal hemorrhage to the fetus or birth malformations.7 Patients with compromised liver function may not be candidates for warfarin, either.

Liver disease reduces the synthesis of clotting factors, so an increased anticoagulant effect is seen in patients with significant liver disease.16 Warfarin may not be the appropriate anticoagulant for a patient with an infection, because the expected decrease in white blood cells that occurs with warfarin therapy can intensify the patient’s risk for more serious infection.

A significant concern related to the use of the DOACs is the reversal of emergent bleeding.17 Idarucizumab (Praxbind) is approved for the reversal of dabigatran’s anticoagulant effects in specific emergent situations, but factor Xa inhibitors

have no antidotes.18 One agent (adexanet alfa) is in development to reverse the effects of indirect and direct factor Xa inhibition, but no decision has been announced about its approval. The use of prothrombin complex concentrates for DOAC reversal has been reported in case reports and small groups of healthy volunteers, but evidence of benefit and effectiveness are limited. Robust, large-scale studies are needed to clarify the place of DOACs in therapy and anticoagulation reversal.17

Where RNs Fit In The Joint Commission Venous Thromboembolism Core Measure Set requires patients admitted to the hospital receive VTE prophylaxis within two days of admission, or a reason why this was not performed must be documented.19 A main priority in the hospital is to assess a patient’s risk for DVT and initiate prevention with mechanical prophylaxis or an anticoagulant medication. The choice and dose of anticoagulant depend on the risk factors for DVT formation and the patient’s overall clinical condition.

One of the highest risks of anticoagulation therapy is the unintended concurrent use of two heparin products (e.g., unfractionated and LMWH heparin), which can result in serious harm or death. The nurse must review the patient’s recent and current medication administration records before giving any heparin or LMWH product. Concomitant use of heparin or LMWH with warfarin is acceptable when a patient is transitioning from heparin to warfarin.

IV administration of heparin also requires careful attention; IV heparin should be administered only with an IV pump, and two RNs should check the bolus dose and the continuous IV dose.5 APRIL 2018 | OR TODAY |

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continuing education Because heparin is available in various concentrations for varied uses, nurses need to ensure that the proper concentration is used for anticoagulation. Bar code tracking of medications or two clinical verification processes can help prevent errors. As outlined earlier, lab monitoring is important for all patients on anticoagulation.9 Once patients are on an anticoagulation regimen, the nurse must assess for frank or occult bleeding, including gingival bleeding, epistaxis, ecchymosis, hematemesis, hematochezia, black tarry stools, and hematuria. A sudden drop in blood pressure, especially orthostatic hypotension, or in hematocrit may suggest bleeding. Continue to assess for thrombosis. Swelling in a unilateral extremity or increased pain in a leg may be secondary to the formation of a thrombus. As with all medication administration, continually evaluate patients for hypersensitivity to the anticoagulant, such as chills, fever, or urticaria (hives).11

All Clear Clear communication with all members of the healthcare team is important while caring for patients on anticoagulants, and patient safety systems enhance communication.

Thorough medication reconciliation during the patient’s care will contribute to effective communication. In addition, all members of the healthcare team must know which patients are receiving anticoagulant therapy, especially team members performing blood draws and placing peripheral and central invasive catheters. Additional pressure is needed for venipuncture and injection sites to prevent bleeding or hematoma.20 IM injections should be avoided in patients receiving anticoagulant therapy.

Patient education about antico-

46 | OR TODAY | APRIL 2018

agulants should begin at admission as providers assess DVT risk. Once therapy begins, patients should know why they are on anticoagulants and why they are important for overall health. The nurse should explain potential adverse effects and instruct patients to report unusual bleeding or bruising. Patients and families benefit from understanding lab values monitored during hospitalization. Patients who understand the importance of DVT prophylaxis will be more apt to adhere to nonpharmacologic approaches, such as frequent ambulation and the use of pneumatic compression devices while in bed.6 For patients who require ongoing anticoagulation after discharge, education about oral anticoagulants should begin well before discharge.

When teaching about warfarin, stress the importance of timely PT/ INR draws and educate patients about food, medication, and herbal interactions. In addition, patients should be advised to minimize risks of falling, to be mindful of excessive bruising, and to be cautious about daily household activities, such as shaving, that may result in bleeding.

Finally, advise patients to wear identification bracelets indicating they are on anticoagulant therapy. As hospitals seek to avoid harm to patients from anticoagulation therapy, knowledgeable bedside clinicians will be important contributors to the safety processes that emerge.21

tor. She is the owner and principal of Excalibur Scientific, LLC.

References 1. Piazza G, Nguyen TN, Cios D, et al. Anticoagulation-associated adverse drug events.

Am J Med. 2011;124(12):1136-42. doi: 10.1016/j. amjmed.2011.06.009.

2. Another heparin error: learning from mistakes so we don’t repeat them. Institute for Safe Medication Practices Web site. http:// www.ismp.org/Newsletters/acutecare/articles/20071129.asp. Published November 29, 2007. Accessed December 29, 2016.

3. Davies T. Fatal drug mix-up exposes hospital flaws. Washington Post Web site. http:// www.washingtonpost.com/wp-dyn/content/ article/2006/09/22/AR2006092200815.html.

September 22, 2006. Accessed December 29, 2016.

4. Making healthcare safer II: an updated critical analysis of the evidence for patient safety practices. Agency for Healthcare Research and Quality Web site. http://www.ahrq.gov/ research/findings/evidence-based-reports/ ptsafetyuptp.html. Published March 2013. Accessed December 29, 2016.

5. National Patient Safety Goals. 2017 National Patient Safety Goals. The Joint Commission Web site. https://www.jointcommission.org/ standards_information/npsgs.aspx. Published 2016. Accessed December 29, 2016.

6. Kahn SR, Lim W, Dunn AS, et al. Prevention of DVT in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines.

Chest. 2012;141(2 Suppl):e195SS-e226S. doi: 10.1378/chest.11-2296.

7. Lexi-Comp’s Drug Information Handbook: A Clinically Relevant Resource for All Healthcare Professionals. 25th ed. Hudson, OH: LexiComp Inc.; 2016.

EDITOR’S NOTE: Gail Armstrong, ND, RN; Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN; and Anna Ver Hage, MSN, AGACNP, CCRN, CNRN, past authors of this educational activity, have not had an opportunity to influence the content of this version.

Jennifer L. Gibson, PharmD, is a pharmacist and medical communica-

8. Chu YQ, Cai LJ, Jiang DC, et al. Allergic shock and death associated with protamine administration in a diabetic patient. Clin Ther. 2010;32(10):1729-1732. doi: 10.1016/j. clinthera.2010.09.010.

9. Linkins LA, Dans AL, Moores LK, et al.

Treatment and prevention of heparin-induced thrombocytopenia: antithromobic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based

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CE463

How to Earn Continuing Education Credit clinical practice guidelines. Chest. 2012;141(2 suppl):e495Se530S. doi: 10.1378/chest.11-2303.

10. Vallerand AH, Sanoski CA. Davis’ Drug Guide for Nurses.

15th ed. Philadelphia, PA: FA Davis Co.; 2016.

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.

11. Lewis SL, Dirksen SR, Heitkemper MM, Bucher L, Camera I. Medical Surgical Nursing: Assessment and Management of Clinical Problems. 9th ed. St. Louis, MO: Mosby Elsevier; 2013.

12. Mourier PA, Herman F, Sizun P, Viskov C. Analytical comparison of a US generic enoxaparin with the originator product: the focus on comparative assessment of antithrombin-binding components. J Pharm Biomed Anal.

2016;129:542-550. doi: 10.1016/j.jpba.2016.07.033.

13. Alquwaizani M, Buckley L, Adams C, Fanikos J. Anticoagulants: a review of the pharmacology, dosing, and complications. Curr Emerg Hosp Med Rep. 2013;1(2):83-97. doi: 10.1007/s40138-013-0014-6.

14. Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH. Antithrombotic and thrombolytic therapy for valvular disease: antithrombotic therapy and prevention of thrombosis.

9th ed: American College of Chest Physicians evidencebased clinical practice guidelines. Chest. 2012;141(2 Suppl):e576S-e600S. doi: 10.1378/chest.11-2305.

Deadline Courses must be completed by 1/31/2019 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.

15. Trautmann A, Seitz CS. The complex clinical picture of side effects to anticoagulation. Med Clin North Am. 2010;94(4):821-834. doi: 10.1016/j.mcna.2010.03.003.

16. Lamarche K, Heale R. Communicating the safety essentials of oral anticoagulant therapy. Home Healthc Nurs. 2007;25(7):448-456. doi: 10.1097/01.

NHH.0000281612.50929.1a.

17. Brown KS, Zahir H, Grosso MA, et al. Nonvitamin K antagonist oral anticoagulant activity: challenges in measurement and reversal. Crit Care. 2016;20(1):273. doi: 10.1186/ s13054-016-1422-2.

18. Fellner C. Pharmaceutical approval update. P T.

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.

2015;40(12):807-808.

19. Core measure sets. Joint Commission Web site. http:// www.jointcommission.org/core_measure_sets.aspx. Published 2016. Accessed December 29, 2016.

20. Zengin N, Enc N. Comparison of two blood sampling methods in anticoagulation therapy: venipuncture and peripheral venous catheter. J Clin Nurs. 2008;17(3):386-393. doi: 10.1111/j.1365-2702.2006.01858.x.

21. Ha NB, Yang K, Hanigan S, et al. Impact of a guideline

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for the management of antimicrobial/warfarin interactions in the inpatient setting and across transition of care. Ann Pharmacother. 2016;50(9):734-740. doi: 10.1177/1060028016653765.

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47

IN THE OR

continuing education

Clinical Vignette for CE463 Sara, a 36-year-old woman, is admitted to your medical floor directly from her primary care physician’s office with the diagnosis of asthma exacerbation. Her vital signs are 134/88, 94, 28, 99.4, and 88% oxygen saturation on room air. You place her on 2 L of oxygen via nasal cannula; her oxygen saturation rises to 95%, and her respiratory rate decreases to 22 respirations/minute. You auscultate Sara’s lungs, and she has expiratory wheezes with diminished breath sounds in the lower lobes bilaterally. During the admission process, Sara tells you that along with chronic asthma, she has hypertension, for which she takes lisinopril (Prinivil) 10 mg daily.

She uses a fluticasone propionate (Flovent) aerosol inhaler twice a day to keep her asthma under control. In addition, she was just diagnosed with type 2 diabetes and takes 500 mg metformin (Glucophage) by mouth twice daily. Sara weighs 220 pounds and is 5 feet 8 inches tall. Her BMI is 33.4 (a BMI higher than 30 qualifies Sara as obese). Sara takes oral contraceptives every morning.

1 The physician who will be caring for Sara

calls you from the ICU and says that he will see Sara later in the shift. You report that Sara’s respiratory status is stable. The physician asks you about Sara’s risk for deep vein thrombosis. You respond that: a. Her risk is low. b. Her risk is high. c. You don’t have to worry about DVT risk because she is being admitted for an asthma exacerbation. d. Her risk cannot be assessed at this time.

2 The physician starts Sara on 40-mg enoxa-

parin (Lovenox) subcutaneously each day.

Which baseline labs will you want drawn before you begin this prophylactic treatment for DVT? a. A CBC and liver function labs b. A CBC and creatinine clearance c. A creatinine clearance and fibrinogen d. Liver function labs and activated partial thromboplastin time (aPTT)

3 Sara’s baseline platelet count was 150,000/

mcL at admission. Two days later, before administering the 0900 dose of enoxaparin, you discover that her platelet count is 85,000/ mcL. What is your response to this drop in platelet count? a. You give the 0900 dose of enoxaparin anyway. b. You wonder whether she is becoming dehydrated and check the specific gravity of her urine. c. Concerned about this thrombocytopenia, you hold the dose of enoxaparin and call the physician. d. You call the physician, requesting to change Sara to subcutaneous heparin.

4 Sara’s hospitalization is complicated by the

development of a DVT. What oral anticoagulant will most likely be prescribed at discharge? a. Enoxaparin (Lovenox) b. Dalteparin (Fragmin) c. Warfarin (Coumadin) d. Protamine

1. Answer: B, Certain people are at an increased risk for a DVT. Risk factors include surgery, decreased mobility, congestive heart failure, respiratory disease, cancer, estrogen therapy, age older than 40, obesity, smoking, or a family history of DVT. This patient has more than one risk factor, which places her at a higher-than-normal risk for DVT development. 2. Answer: B, A CBC and creatinine should be drawn before starting any form of low-molecular weight heparin, as this classification of drugs is partially excreted by the kidneys. Therefore, patients with poor renal function will need a lower dosage. LMWH can cause heparin-induced thrombocytopenia, and a baseline platelet count is necessary. 3. Answer: C, Heparin-induced thrombocytopenia is a severe complication of heparin therapy caused by antibodies to complexes between heparin and platelet factor 4. HIT should be suspected when a patient develops thrombocytopenia while receiving heparin — particularly if the drop is more than 50% from baseline and even if the platelet count remains within a normal range. 4. Answer: C, Warfarin (Coumadin) is the most common oral anticoagulant prescribed at discharge. Patient education will include the importance of frequent lab monitoring, awareness of adverse effects, and knowledge of food and medication interactions.

In addition, patients should be advised to minimize their risks of falling, to be mindful of excessive bruising, and to be cautious about daily activities, such as shaving, that may result in bleeding.

48 | OR TODAY | APRIL 2018

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CORPORATE profile Cygnus

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PROFILE

ygnus Medical™ provides innovative medical products and services. A leader in the industry, Cygnus Medical does more than listen to customers. The company develops unique, industry-first solutions to specific problems found in hospitals and health care facilities.

C

The Airtime Scope Dryer

Studies indicate there is a strong correlation between moisture and microbe colonization within instrument channels. Cygnus Medical is currently launching the Airtime Instrument Channel Dryer. This product dries flexible endoscope channels, as well as other cannulated surgical instruments. The Airtime Dryer is unique in that it can serve as a stand-alone solution for drying

50 | OR TODAY | APRIL 2018

instrument channels, or it can be used to expand the capabilities of drying cabinets that a facility may currently be using. For example, if a facility uses cabinets that only dry the instrument’s exterior, Airtime can be used prior to storage to dry the instrument’s channels.

Scopes that are removed from the AER and needed for a procedure can be quickly dried which ensures that scopes are not stored or put into immediate use with wet channels. Properly drying channels reduces the risk of infection.

Airtime is a practical and affordable solution that doesn’t skimp on features. It is a “true” two-pump system that offers users the ability to dry two instruments simultaneously without any loss of air pressure. In addition, it features a filtration system that surpasses the systems in other similar products now in the marketplace. It uses .01 HEPA filtered air (and is also available with a medical grade option) to dry channels after automated reprocessing, and is compliant with the newest AAMI ST 91 standards.

Disposable Airtime adapters and daily tubing sets

allow for fast and easy set up, while reducing the risk of cross-contamination.

For Endoscopes and Surgical Instruments: • Airtime uses HEPA filtered air to dry the air/water, suction and auxiliary water channels after automated reprocessing.

• Uses two independent pumps and timers that will dry two scopes simultaneously. Air pressure will not drop when you begin drying a second scope.

• Airtime’s dual screen allows for two scopes to be dried with independent start and stop times.

• Restricted channel sensors will immediately shut off the Airtime pump and alert the user of a potentially clogged channel.

• Available options: IV pole mounted, wall mounted or on a table stand.

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As the market transitioned into single-use options for transporting soiled endoscopes, most options offered little to no support or protection for the scope. As a rigid disposable option, the Oasis™ Scope Transport Tray was the first disposable tray suitable for clean and soiled instruments.

Lapses in the cleaning of reusable endoscope transport trays can lead to crosscontamination in the surgical work area. The Oasis Scope Transport Tray offers an economical single-use alternative that protects patients and staff from contamination and infection. Bedside cleaning is performed within the Oasis Tray, keeping residual run-off contained. This creates a cleaner work environment and reduces the risk of hospital-acquired infections.

Oasis Trays are latex-free and are made of a biodegradable plant-based material. This is a 100 percent renewable resource reducing the facility’s carbon footprint. The Tray’s rigid construction protects and contains endoscopes during transport and is large enough to safely hold an endoscope without damaging it. The Oasis Tray’s color-coded reversible lid clearly differentiates clean (green) and soiled (red/orange) scopes. They WWW.ORTODAY.COM

are space efficient, stackable and nestable. Also, the trays meet SGNA recommendations for transporting soiled scopes in a closed container to prevent the spread of infection.

and dispensing it uniformly was difficult. The First Step Bedside Kit simplified the endoscope cleaning process by providing the supplies needed to prevent bioburden from

The First Step Bedside Kit

Prior to the introduction of the First Step™ Kit, the bedside cleaning of flexible endoscopes was a cumbersome step that was often skipped. Although society standards and manufacturers’ instructions for use required bedside cleaning, properly preparing the detergent

drying and solidifying in the endoscope’s channels. Today, industry compliance has dramatically elevated and bedside endoscope cleaning is recognized as an essential step in the cleaning process.

First Step Kits are available in Ready-to-Use and Add Water Kits.

APRIL 2018 | OR TODAY |

51

CORPORATE profile Cygnus

Ready-to-Use Kits offer convenience of use, which increases staff compliance and turnover time. The readyto-use detergent ensures a properly mixed formula every time. The combined effect is 100% compliance, 100% of the time. The 500 ml Add Water Kit offers ease of storage and a reduction in shipping costs because water is added at the point of use.

The Kits are 100 percent compliant with SGNA and manufacturers’ guidelines, safe for use on all flexible endoscopes, and available with a variety of cleaning pad options, including the popular Draco Microfiber DeepCleaning Pad. First Step Pouches are also user-friendly and space-efficient. All First Step Kits ensure the proper dilution of enzymatic detergent, and are available in 100 ml, 200 ml and 500 ml sizes.

All Kits contain Simple2™ Multi-Tiered Enzymatic Detergent and an endoscopic cleaning pad. Simple2 effectively dissolves blood, fat, tissue, protein and other forms of organic material. Simple2 is low-foaming, nontoxic, non-corrosive, latex-free, neutral pH and safe to use on all flexible endoscopes.

Health care studies and data continue to show the limitations and ineffectiveness of manual cleaning products for flexible endoscopes. Cygnus Medical has taken the amazing properties of microfiber and adapted it for use in cleaning difficult to reach endoscope channels.

The patented Dragontail™ cleaning element is constructed of multiple lint-free Draco™ microfiber strands that are able to capture particles at a 4-micron level as it passes through the endoscope’s channel. Unlike bristles or silicone discs, which glide over adhered contamination, the microfiber cleaning element detaches, captures and removes gross contamination. In a comparative study, under identical conditions, the Dragontail™ Channel Brush cleaned 468 times more contamination than a traditional style channel brush.

These are just a few of the innovative products Cygnus Medical offers its health care customers.

For more information about these products and several others, visit cygnusmedical.com.

The Dragontail™ Microfiber Channel Brush

52 | OR TODAY | APRIL 2018

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instrument channel dryer

CAIP CAIP IP 54 | OR TODAY | APRIL 2018

WWW.ORTODAY.COM

P H

Certified A m b Iun f elc tai o ntP roe vre n tyi o n

By Don Sadler

ospital infection preventionists have

long been able to obtain the Certification in Infection Control and Prevention, or CIC, credential. But a similar credential hasn’t been available for infection preventionists who work in ambulatory surgery centers (ASCs).

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APRIL 2018 | OR TODAY |

55

CAIP Fortunately, this is about to change.

Earlier this year, the Board of Ambulatory Surgery Certification (BASC) announced the creation of the Certified Ambulatory Infection Prevention, or CAIP, credential.

A Consistent Mechanism

BASC President John J. Goehle, MBA, CPA, notes that ASCs are required to have an infection control coordinator on staff who has received appropriate training to carry out his or her responsibilities.

“Up until now, though, there hasn’t really been any consensus on what type of training and certification would be appropriate in the outpatient setting,” he says. “The new credential will provide ASCs with a consistent mechanism to prove their compliance with the licensure, certification and accreditation requirements related to the training of infection control coordinators.”

According to Gina Throneberry, RN, MBA, CASC, CNOR, the Director of Education and Clinical Affairs for the Ambulatory Surgery Center Association (ASCA) and Executive Director of the BASC, those in the industry have long known that a certification for infection preventionists in the ASC industry has been needed.

“It’s a lengthy process to get a new credential up and running, with lots of

moving parts and pieces,” says Throneberry. “We started this process all the way back in 2015.”

The first step was the creation of a job analysis task force.

“This task force was composed of ASC personnel who were experienced in infection prevention,” says Throneberry. “Next, we surveyed ASCA members to help us determine the specific activities and responsibilities to be performed by infection preventionists in an ASC.” The task force, with assistance from a testing vendor, was then ready to create a content outline. Once the content outline was obtained, the CAIP writing committee began writing exam questions, which Throneberry says “was a very detailed process.”

Throneberry is excited to announce that the first CAIP exam will be administered between October 1 and October 31 of this year. Applications for the exam can be submitted electronically between August 1 and August 31 of this year.

The CAIP exam will include five separate sections that test knowledge in the following categories: 1. Infection prevention program development, implementation and maintenance 2. Infection prevention and control education and training

“

3. Surveillance, data collection and analysis 4. Infection prevention strategies 5.

5. Instrument/equipment cleaning, disinfection and sterilization

Why CAIP is Needed

For those who wonder why a separate credential is needed for infection preventionists working in ASCs versus those working in hospitals, Throneberry says the two environments are different from an infection control standpoint.

“For example, ASCs don’t perform emergent cases,” she says. “All procedures are outpatient and we know the patients are coming in. Also, ASCs don’t treat patients requiring airborne precautions.”

Infection prevention is just as high a priority in the ASC setting as it is in hospitals, Throneberry adds.

“Practically speaking, the CIC exam doesn’t work for our industry, so we needed to create an exam and certification that are unique to ASCs,” she adds.

According to Goehle, the goal in creating the CAIP credential is to provide a relevant pathway for ASC infection control coordinators to: • Receive appropriate and relevant training.

• Provide an opportunity to demonstrate a high level of understanding of

The new credential will provide

ASCs with a consistent mechanism

to prove their compliance with the licensure, certification and

accreditation requirements related to the training of infection control coordinators.

J o h n J . G o e h l e , M B A , C PA BA S C P r e s i d e n t

56 | OR TODAY | APRIL 2018

WWW.ORTODAY.COM

P “ ”

Certified Ambulatory Infection Prevention P r a c t i c a l ly s p e a k i n g , t h e C I C exam doesn’t work for our

i n d u s t r y, s o w e n e e d e d t o c r e at e an exam and certification that are unique to ASCs.

G i n a T h r o n e b e r r y , R N , M BA , CA S C , C N O R D i r e c t o r o f E d u c at i o n a n d C l i n i c a l A f fa i r s f o r t h e A m b u l at o r y S u r g e r y C e n t e r A s s o c i at i o n ( A S CA ) a n d E x e c u t i v e D i r e c to r o f t h e BA S C

those responsibilities through the CAIP credential.

“The new CAIP credential will provide perioperative nurses with a well-defined educational pathway toward certification as an ASC infection control professional,” Goehle says. “And it will demonstrate to patients that the organization is committed to high-quality care, especially as it relates to infection control.”

Infection prevention and control is always on the surveyors’ radar, Throneberry adds.

“And it’s always on our mind – it’s something we strive for every day,” she says.

Excitement is Building Throneberry and Goehle say that there has been tremendous feedback and excitement in the industry about the introduction of the new CAIP credential.

“The feedback has been overwhelmingly positive,” says Goehle. “Many professionals have noted that such a certification has been long-needed. The rollout of the education in anticipation of the new credential has been particularly well received.”

For example, Throneberry says it was standing-room only attendance at the ASCA winter seminar sessions where the new credential was discussed.

“There’s definitely a hunger out there for this kind of education and WWW.ORTODAY.COM

certification,” she says.

There will be two full days of infection prevention education at ASCA 2018 in Boston in April, Throneberry adds.

Here’s a sampling of some of the feedback the ASCA has received from industry professionals about the new CAIP credential: “With the CAIP certification, ASC infection preventionists can show they are committed to developing the highest level of infection control skills,” says Lee Anne Blackwell, RN, BSN, EMBA, CNOR. “Certification distinguishes the infection preventionist as a leader devoted to ambulatory surgery infection prevention standards and best practices and is a symbol of dedication to personal development,” says Lisa Berus, RN, MSN, MEd, CASSPT. “The CAIP credential will allow clinicians to proudly display that they have achieved a certification because they want to be the best in the ambulatory industry when it comes to infection prevention,” adds Ann Geier, MS, RN, CNOR, CASC. “CAIP is geared toward our needs and standards which, in some areas, are different from that of a hospital,” says Tammeria Tyler, RN, CIC. “In becoming CAIP certified, perioperative nurses will designate themselves as a certified professional in infection prevention in the ASC setting.”

“This is an exciting journey as the CAIP exam will be administered specifically for ASC infection preventionist to test knowledge distinctive to our industry,” adds Mary Ryan, BSN, MBA, CASC. “Make sure your center’s infection preventionist is leading the way by becoming certified!”

Obtain a Candidate Handbook If you’d like to learn more about the new CAIP credential, visit the CAIP website at aboutcaip.org.

You can download a Candidate Handbook from the website AboutCAIP. org that contains more details on the credential as well as exam policy and procedures, eligibility requirements and exam preparation.

Copyright © 2017. BASC. All right reserved.

APRIL 2018 | OR TODAY |

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spotlight on

By Matt Skoufalos

RN, BSN

I

n the beginning, Claudia Pianti didn’t anticipate a career in nursing.

“I went to college with the idea of being a writer,” Pianti said. “I was a liberal arts major for about three years. In my junior year, people asked what would I do with my degree; I really didn’t want to be a teacher.”

With several family members in the medical field, including her mother (a nurse) and father (a CRNA), Pianti thought she’d follow suit. After completing some prerequisite courses at Camden County College in New Jersey, Pianti transferred across the Delaware River, to Thomas Jefferson University Hospital in Philadelphia, Pennsylvania. From there, she was hired at Hahnemann University Hospital, and was thrust right into a role in vascular surgery.

“In nursing school, you don’t really learn about the operating room,” Pianti said. “Maybe you sort of touch on it, and if you’re lucky in your clinicals,

60 | OR TODAY | APRIL 2018

you maybe get one day of shadowing.

When it came to the operating room, there was really no background for me; it was all new.”

Pianti described her experience as “sink or swim.” She was partnered with a seasoned colleague who she described as knowledgeable but very laissez-faire. Pianti said she felt free to make mistakes, but also a great deal of stress in the on-the-job learning environment. When a group of her fellow new hires gathered to discuss their respective experiences within the hospital, Pianti said she found their experiences didn’t compare with hers.

“I remember wanting to cry,” she said.

“[I felt like] I don’t know what I’m doing; there’s no one to teach me anything.”

“With different personalities, you learn different things,” Pianti said.

“Some people like to teach, some people don’t, and you get the perspective of how to do it on your own.”

Finally, Pianti mustered the nerve to approach her manager to discuss her circumstances, and he responded by pairing her with a few different mentors. The changes were significant.

“They teach you to advocate for yourself in nursing school, but in real time, it’s a lot more difficult to know if your feelings are legitimate or if you’re scared,” WWW.ORTODAY.COM

1 Claudia pictured with her daughter Sophie. 2 Claudia Pianti,

RN, BSN, posing outside her surgical unit at Vincera Insitute at the Philadelphia Navy Yard. 3 Claudia pictured with her son Simon.

1

she said. “At the time I didn’t realize it, but a really good manager who will listen to their staff is a valuable thing to have. If he’d just written me off, I probably wouldn’t have had such a good training experience after speaking up for myself.”

The positive reinforcement of that experience taught Pianti a lot, and as a result, she ended up mentoring a few colleagues later in her time at Hahnemann. Her takeaway? Investment in developing strong coworkers produces a more cohesive workplace.

“If you don’t train the people you work with well, you’re selling yourself short, and you’re selling them short,” Pianti said. “It really is a team effort to make sure that everybody is comfortable and knowledgeable in their position.”

After Pianti and her husband had a second child, she transitioned to the Vincera Institute, a sports medicine clinic and surgery center located in the Philadelphia Navy Yard. Its principal clientele includes collegiate and professional athletes, as well as “weekend warriors” who go a little too hard in their recreational leagues, she said.

Splitting time on a per-diem basis WWW.ORTODAY.COM

2

between the Vincera Institute and Hahnemann was made easier by the fact that a handful of the Hahnemann staffers with whom she trained also took positions there. As she transitioned to Vincera full-time, the small, tight-knit group felt “almost like going to work with a bunch of friends,” Pianti said, with colleagues taking up for one another to account for their lack of a second shift. It gets busy around the holidays, but with a staff of parents, “we all understand the plight of having to get everyone to dance class on time,” she said.

“It allows us to take care of our patients really well and maintain a good work-life balance,” Pianti said.

When she’s not working, Pianti likes to read, cook and garden; running also offers some necessary alone time. A busy mom to Sophie, five, and Simon, three-and-a-half, having the clarity of some quiet time is just as important to her ability to do the job as it is to her own wellness.

“It’s really important to carve out a little bit of time to go for a jog, listen to some music or a podcast, or just my own thoughts,” Pianti said. “My favorite activities are very solitary.”

3

As meaningful as on-the-job training and being a supportive coworker are to her career success, Pianti also stressed the importance of advanced education.

With an interest in system issues like women’s health, environmental health, and workplace safety, she would like someday to pursue a master’s degree in public health. The ability to shift specialties is a hallmark of the nursing trade, often cited as a value of keeping people interested in their careers, but for Pianti, advanced schooling is about her passion for learning. “[In nursing], you can find yourself in one area while still jumping to another,” she said. “You’re always building on your education, and it’s never boring because there’s always something new to find out.”

Pianti advised young nurses to pursue advanced degrees wherever possible and recommended seeking positions with employers who will offer tuition reimbursement as well.

“Keep educating yourself,” she said. “It’s a very interesting field, and there’s always new things to learn. Keep an open mind, get your education and take care of yourself.”

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OUT OF THE OR fitness

Lower Life Expectancy Likely Caused by Lifestyle Choices or the first time in two decades, the life expectancy of Americans declined slightly, and the overall death rate rose, according to a report from the National Center for Health Statistics.

F

While that information shouldn’t alarm many, it does point to challenges in keeping America healthy.

“A lot of people are still trying to understand the data and speculate on what the report means based on the information we have,” said Nicole Osevala, M.D., an internist and geriatrician at Penn State Health Milton S. Hershey Medical Center.

Osevala said the life expectancy report was broken down into age ranges, and adults age 65 and older saw no decrease in how long they are expected to live.

The decrease in life expectancy comes into play for the younger and middle-aged population. For those under the age of 65, accidental deaths and complications from chronic diseases such as heart disease, renal disease, stroke and diabetes were the causes of death that saw increases in 2015.

64 | OR TODAY | APRIL 2018

“It’s concerning because in many ways, these are linked to lifestyle choices and obesity,” Osevala said.

“And those are problems we don’t necessarily have medications for.”

Whether it’s young people abusing opiates or texting while driving, or middle-aged folks failing to get exercise and maintaining poor diets, such lifestyle choices aren’t entirely within the control of the medical community.

“All of our medical knowledge, interventions and medications don’t seem

likely due more to better diagnosis and reporting than the fact that more people are dying from the disease than they were before. An increase of more than 2 percent in the suicide rate leaves her wondering if the country has adequate resources available to treat people with mental health issues in a continuous way.

The one positive piece of the report was the decrease in cancerrelated deaths.

Osevala pointed out that the

“We can counsel and educate patients, but we are not in their homes 24 hours a day, seven days a week. It’s the day-to-day choices we are making that have the biggest impact.” to be making an impact on preventing these diseases from killing people,” Osevala said. “We can counsel and educate patients, but we are not in their homes 24 hours a day, seven days a week. It’s the day-to-day choices we are making that have the biggest impact.”

She said a significant increase in deaths from Alzheimer’s disease is

-Nicole Osevala

report shows a year of data and not a trend, so the numbers aren’t cause for alarm. Yet she finds it disappointing that the United States, with its advanced medical interventions, isn’t seeing an increase in life expectancy like Japan and some European countries.

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65

OUT OF THE OR health

Do 1 More Thing to Resist the Flu

BY MARILYNN PRESTON was driving the other morning, listening to one of my favorite radio interview shows. The topic of the day was the flu.

I

The flu! After a few noisy coughs, I leaned right in, because pretty much everyone I know either has the flu, had the flu or is about to get the flu.

“It’s very bad this year,” the two doctor guests agreed, both experts in the flu and flu vaccines. And California is especially hard hit, said host Michael Krasny.

Health officials throughout the state report a skyrocketing number of flu cases: 1,646 so far, compared with 451 at a similar point last year. In San Diego County alone, there have been at least five recent deaths of flu victims under 65.

I checked the Centers for Disease Control website later that day, and sure enough, the whole country is suffering from increasing cases of the flu and all the suffering and medical bills that follow.

“Influenza activity increased sharply again in this week’s FluView report,” read the warning in their online report. “The number of jurisdictions experiencing high activity went from 21 states to 26 states.”

One of the problems is the lack of effectiveness of this year’s flu vaccine, recommended highly by the CDC for everyone over six months old. It’s only 32 percent effective, Krasny reported. It’s not a secret. Neither doctor refuted him.

Thirty-two percent effective is better than nothing, the experts said. The CDC agrees. They consider taking the flu vaccine as the single most important thing you can do to prevent the flu.

66 | OR TODAY | APRIL 2018

Really? The most important thing a person can do?

Krasny asked the doctors about prevention. “We know about hand-washing.

But what else?”

Great question. Prevention! What can a person do to keep from getting the flu?

“Take the flu vaccine,” the doctors kept repeating. “And wash your hands. And if you feel sick, stay home from work or school so you don’t make other people sick.”

I listened to this interesting discussion about the flu for 25 minutes of a 30-minute segment, and when I turned it off in the parking lot of my yoga class, I knew I had a column.

Yes, dear readers, flu vaccines can be helpful, and washing your hands periodically during the day is very smart, but as your most personal trainer I want to mention another strategy for fighting off the flu virus and all its nasty friends.

It’s a strategy that I think is every bit as important as taking a flu vaccine that is 32 percent effective. It’s actually more important, in the long term.

Drum roll, please.

Strengthen your immune system! You have one. Everyone does. And the sooner you tune in to yours – and what it needs to become stronger and more protective – the less likely you will be to come down with a debilitating, even deadly, case of the flu. Is it 100 percent effective? No. Nothing is.

What is your immune system exactly?

To cover the “exactly” would take volumes, so for now let’s go with something simple from Harvard’s health department: “It’s an extremely complex net-

work of cells and molecules.” Translation: There’s no place in your body that your immune system is not. I like to think of it as a gel-like matrix of potential.

It’s your immune system that protects you from the disease, suffering and death caused by viruses, infectious bacteria, fungi, parasites and more. So again, vaccines can be helpful and hand washing is de rigueur, but don’t forget the incredible power you have to engage with your immune system in ways that make it more effective, more protective and more resilient.

The only question is, when will you decide to take action?

“Get plenty of sleep. Be physically active. Manage your stress. Drink plenty of fluids, and eat nutritious food,” it says deep into the CDC site, the last line of the last paragraph of a page called “Preventing the Flu.” I’m sorry the doctors on the radio show spent all that time promoting the flu vaccine and no time promoting healthy lifestyle changes.

I guess they think those golden health clichés fall on deaf ears.

I don’t agree. I think people are sick and tired of being sick and tired. Educate them. Coach them. Inspire them to boost their immune system. Do all this, and many fewer people will get sick from the flu, period.

It’s certainly worth a shot.

– Marilynn Preston is the author of Energy Express, America’s longest-running healthy lifestyle column. For more on personal wellbeing, visit www.MarilynnPreston.com.

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OUT OF THE OR nutrition

Brighten Your Day with Red Produce

By Judith C. Thalheimer

T

here is nothing like red to warm our hearts ... and protect them, too. Here’s an in depth look at some of the season’s reddest, healthiest choices.

Pomegranates: Pomegranates are a good source of blood-clotting vitamin K, tissuerepairing antioxidant vitamin C, and filling fiber, but they really stand out for their phytochemicals. The rich, red color of this fruit comes from flavonoids called anthocyanins, which have been linked to numerous health benefits including lower risk of coronary artery disease.

Pomegranates also contain ellagic acid, which has been investigated for its cancer-fighting and anti-inflammatory effects. Submerge cut sections in a bowl of water while gently removing the edible seeds.

After straining, sprinkle on salads or

68 | OR TODAY | APRIL 2018

meat and fish dishes for a delicious pop of color.

Cranberries: While cranberries, like pomegranates, get their red color from health-promoting anthocyanins, they also contain phytochemicals with anti-bacterial properties.

Cranberry juice is commonly used for prevention and treatment of urinary tract infections. These sour jewels are also an excellent source of vitamin C and manganese, which supports bone health. Enjoy dried cranberries in cereals, salads and side dishes (but be aware that they have added sugars). Buy fresh berries that are firm and not shriveled for relishes, sauces and jellies.

Beets: Arguably the reddest of the red produce, earthy beets are an excellent source of bone-building manganese, the B vitamin folate, and fiber, and have plenty of vitamin C and bloodpressure-lowering potassium as well.

That deep red color comes from potent antioxidant compounds called betalains, which interfere with the formation of arterial plaque. Beets also provide betaine, which may protect cells from stress. The nitrates in beets help blood vessels dilate, so beet juice is popular with athletes looking to speed the delivery of oxygen to muscles. Look for smaller

beets with firm, smooth skins. Rub with olive oil and roast to bring out beets’ natural sweetness, or bake, boil or sauté.

Red Pears: Red d’Anjou pears are fresh and sweet at a time of year when fresh fruit is in short supply. An excellent source of fiber and a good source of vitamin C, red pears also are packed with phytochemicals called anthocyanins and triterpenoids, which have antioxidant and anti-inflammatory properties.

But these phytochemicals, as well as the vitamin C and a lot of the insoluble fiber, are concentrated in the tender skin, so enjoy these pears un-peeled for the biggest nutritional impact. D’Anjou pears, ripe when they yield to slight pressure at the neck, are perfect for snacking, with cheese and in salads. Bake, roast or poach for a special dessert.

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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

INGREDIENTS: •

• •

70 | OR TODAY | APRIL 2018

2 pounds baking potatoes or 4 medium baking potatoes (1 medium potato per serving, depending upon your appetite) Peanut oil Salt

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OUT OF THE OR recipe

Homemade French Fries Are Worth the Time I love french fries, but I try to be good when I am out at a restaurant. If I really want them I make them myself.

French fries aren’t hard to make. They just require some advance organization and a few tools: a sharp knife, a deep fryer or a deep heavy cast iron skillet, a fry basket and a deep fry thermometer.

The keys to crisp french fries are using fresh oil, having the oil at a constant high temperature and making sure that the potatoes are dried. As far as how many these homemade fries will serve, it really depends upon who is eating them. I figure one potato per person but you can judge how much you need depending upon your group, The traditional method requires cooking the potatoes twice. The first cooking time sets the potatoes and cooks the inside. The second cooking time finishes cooking the

potatoes and makes them crisp and golden brown.

Don’t crowd the potatoes, because this will bring down the frying temperature and make the french fries too oily. Remember, the temperature goes down as soon as you add the potatoes. That is why it may take a few more minutes for the first frying.

You’ll also find methods for frying shoestring below.

And while the recipes here recommend peeling the potatoes, you may prefer a more rustic presentation with the peel on. Either way they’re delicious.

There a number of ways to cut the potatoes: try the french fry cutter disc on the food processor, any of the french fry gadgets or a very sharp knife. If you like to dip your fries, why not try a garlic mayonnaise instead of ketchup? Or, offer both if you can’t decide. Serve these on a plate or in a basket.

French Fries Serves 4 1.

2.

3.

Peel the potatoes and cut into 3/8 inch by 3/8 inch by 4 inches. Cover in cold water for a few minutes to remove excess starch.

Heat about 3 inches of oil to 330 F in a deep fryer with a basket or in a heavy deep pan. If you don’t have a deep fryer, use a deep-fry thermometer to register the temperature. If you don’t have a basket to keep the fries together, use a pair of long tongs to remove them from the oil.

While the oil is heating dry the potatoes carefully with dishtowels. (Wet potatoes splatter and may stick together.)

Immerse the basket in the hot oil to avoid the potatoes sticking. Remove the basket from the oil. Place 2 cups of potatoes at a time in the basket or in the pan and lower into the oil. The oil will expand and cover the potatoes.

4.

5.

Fry for about 4 to 5 minutes or until the potatoes are light yellow but have not started to brown. Adjust the temperature so it stays at 330 F. Make sure that you do not crowd them. Remove the basket over a bowl to drain and then set aside for at least 10 minutes. These may be held at room temperature for up to 2 hours.

Right before serving, heat the oil to 370 F and fry the potatoes again, in batches, for about 3 to 4 minutes or until golden brown and crisp. Remove the basket and drain over a bowl. Transfer and drain on paper towels.

Place in a serving bowl or basket, season with salt and serve immediately.

Shoestring Potatoes Serves 4 1.

2.

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These are only cooked once. Cut peeled potatoes into skinny strips (1/4 inch by 1/4 inch by 3 inches). Cover in cold water for a few minutes to remove excess starch.

Heat the oil to 375 F. While the oil is heating dry the potatoes carefully with dish towels. Add the potatoes in batches (1 potato at a time), stirring with long tongs to make sure they don’t stick together.

3.

When golden brown, remove the basket over a bowl to drain and then turn out on paper towels to blot the excess oil off. Place in a bowl or napkin-lined basket, season with salt and serve immediately.

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71

OUT OF THE OR pinboard

OR TODAY

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Snap a selfie and email it to Editor@MDPublishing.com to enter. Good luck!

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The News and Photos that Caught Our Eye This Month

OUT OF THE OR pinboard

Warm up to grapefruit Most supermarkets are stocked with a wide selection of fruit yearround. However, just because it’s available doesn’t mean it’s at its peak. Now, is the perfect time to enjoy grapefruit!

Grapefruit season is yearround but it peaks from December to April.

If you love sour candy, tart grapefruit is a healthier alternative. If not, opt for the sweeter new varieties, like White Gold and Sweet Scarlett’s. Grapefruit is packed with antioxidants, but one caveat: if you’re taking any prescriptions (including some

antihistamines), check with your doctor; grapefruit doesn’t mix well with some meds.

When purchasing, look for round, heavy fruit without soft spots or deep blemishes.

One tasty idea is to sprinkle four halves with 1 to 2 teaspoons of brown sugar or honey and top with 1/4 teaspoon cinnamon each. Place on a parchmentlined baking tray and broil until slightly browned, about 5 to 7 minutes.

– parents.com

Need a vacation where it’s warm?

Florida’s Space Coast, where it’s decidedly warmer, has something for everyone. From rockets launching into outer space to unforgettable seafood and more, the Space Coast is an affordable and worthwhile escape, even for just a weekend. So, take next Friday off, book your tickets or gas up the car, and get ready to experience these Space Coast attractions and activities.

• Explore the final frontier. As you might have guessed, the Space Coast got its name because it is home to the Cape Canaveral launch

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complex and NASA’s Kennedy Space Center.

Here, rockets operated

by SpaceX and others still regularly blast into the heavens. A day at the Kennedy Space Center Visitor Complex will bring you up close to one of the legendary Apollo command modules that orbited the moon, as well as the last Space Shuttle orbiter to fly. You’ll learn about the history of the NASA program and maybe even see a rocket launch!

It’s an interactive journey that will inspire the entire family.

• Hang loose at Ron Jon Surf Shop. You’ve seen the iconic shirts and the ubiquitous roadside billboards, but nothing can really prepare you for a visit inside Ron Jon’s flagship store in Cocoa Beach. With more than 52,000 square feet of merchandise space, it’s like nothing you’ve experienced at the shore before. You’ll find everything to outfit

your beach-bum vacation lifestyle, and maybe a few items that will fit in back home, too.

• Embark on a zoo adventure like no other. At the Brevard Zoo, you can kayak past exotic animals, feed a giraffe, zip line over the treetops and get an eyeful of hulking rhinoceros. With a wide array of animal species on hand and a variety of fun activities and educational opportunities available, this unique facility is set up to be more of an adventure than a walk-through.

• Enjoy the fresh air. Its sunshine and mild temperatures make the Space Coast perfect to visit at this time of year. For those who like to be outside, there is a healthy range of options. You can spend an afternoon bird watching in nearby wetlands, walking along the beach (and enjoying the ocean breeze) or even fishing along the shore or on one of the many inland bodies of water.

– Brandpoint

APRIL 2018 | OR TODAY |

73

INDEX

advertisers

Alphabetical Arthroplastics, Inc.…………………………………………17 AIV Inc.………………………………………………………… 15 Alco Sales Service, Co.……………………………… 69 ASCA…………………………………………………………… 65 C Change Surgical……………………………………… 13 Capital Medical Resources………………………… 69 Cincinnati Sub-Zero…………………………………… 58 Cygnus Medical………………………………… 9, 50-53 D. A. Surgical……………………………………………… 75

Diversey ……………………………………………………… 38 Doctors Depot…………………………………………… 63 Dräger Medical, Inc.………………………… 18-19, 59 Healthmark Industries Company, Inc.……… 4 Innovative Medical Products…………………… 76 Jet Medical Electronics Inc……………………… 29 Key Surgical………………………………………………… 30 MD Technologies Inc.………………………………… 65 Medi-Kid Co.………………………………………………… 29

MedWrench………………………………………………… 49 Microsystems…………………………………………………21 Mobile Instrument Service & Repair……… 62 Pacific Medical…………………………………………… 39 Paragon Services………………………………………… 20 Ruhof Corporation…………………………………… 2, 3 TBJ Incorporated…………………………………………… 5 Tetra……………………………………………………………… 25 TIDI C-Armor………………………………………………… 6

INFECTION CONTROL

REPAIR SERVICES

categorical ANESTHESIA

Doctors Depot…………………………………………… 63 Draeger Medical, Inc.……………………… 18-19, 59 Paragon Services………………………………………… 20

ASSET MANAGEMENT

Microsystems…………………………………………………21

ASSOCIATION

Alco Sales Service, Co.……………………………… 69 Cygnus Medical………………………………… 9, 50-53 Diversey ..……………………………………………………… 38 Healthmark Industries Company, Inc.……… 4 Ruhof Corporation…………………………………… 2, 3 TBJ Incorporated…………………………………………… 5 TIDI C-Armor………………………………………………… 6

ASCA…………………………………………………………… 65

INSTRUMENT STORAGE/TRANSPORT

CARDIAC PRODUCTS

Cygnus Medical………………………………… 9, 50-53 Key Surgical………………………………………………… 30

C Change Surgical……………………………………… 13 Jet Medical Electronics Inc……………………… 29

Capital Medical Resources………………………… 69 Cygnus Medical………………………………… 9, 50-53 Doctors Depot…………………………………………… 63 Jet Medical Electronics Inc……………………… 29 Mobile Instrument Service & Repair……… 62 Pacific Medical…………………………………………… 39

REPROCESSING STATIONS

TBJ Incorporated…………………………………………… 5

SAFETY

INSTRUMENT TRACKING

Microsystems…………………………………………………21

Healthmark Industries Company, Inc.……… 4 Key Surgical………………………………………………… 30 TIDI C-Armor………………………………………………… 6

Alco Sales Service, Co.……………………………… 69 Cincinnati Sub-Zero…………………………………… 58 Cygnus Medical………………………………… 9, 50-53 Healthmark Industries Company, Inc.……… 4 MAC Medical, Inc………………………………………… 67 TBJ Incorporated…………………………………………… 5

INVENTORY CONTROL

SINKS

Key Surgical………………………………………………… 30

TBJ Incorporated…………………………………………… 5

MONITORS

STERILIZATION

CS/SPD

ONLINE RESOURCE

CARTS/CABINETS

MD Technologies inc.………………………………… 65 Microsystems…………………………………………………21

DISINFECTION Cygnus Medical………………………………… 9, 50-53 Diversey ……………………………………………………… 38 Ruhof Corporation…………………………………… 2, 3

DISPOSABLES

Alco Sales Service, Co.……………………………… 69

ENDOSCOPY

Capital Medical Resources………………………… 69 Cygnus Medical………………………………… 9, 50-53 Healthmark Industries Company, Inc.……… 4 MD Technologies inc.………………………………… 65 Mobile Instrument Service & Repair……… 62 Ruhof Corporation…………………………………… 2, 3

ERGONOMIC SOLUTIONS

Diversey ……………………………………………………… 38

FALL PREVENTION

Doctors Depot…………………………………………… 63 Pacific Medical…………………………………………… 39 MedWrench………………………………………………… 49

OR TABLES/BOOMS/ACCESSORIES

Arthroplastics, Inc.…………………………………………17 D. A. Surgical……………………………………………… 75 Innovative Medical Products…………………… 76

OTHER

AIV Inc.………………………………………………………… 15

OTHER: CRANIOFACIAL RECOVERY PRODUCTS

Medi-Kid Co.………………………………………………… 29

OTHER: PEDIATRICS

Medi-Kid Co.………………………………………………… 29

PATIENT DATA MANAGEMENT

MAC Medical, Inc………………………………………… 67

PATIENT MONITORING

AIV Inc.………………………………………………………… 15 Jet Medical Electronics Inc……………………… 29 Pacific Medical…………………………………………… 39

Alco Sales Service, Co.……………………………… 69

POSITIONING PRODUCTS

GENERAL

Cygnus Medical………………………………… 9, 50-53 D. A. Surgical……………………………………………… 75 Innovative Medical Products…………………… 76 Medi-Kid Co.………………………………………………… 29

AIV Inc.………………………………………………………… 15 Capital Medical Resources………………………… 69

HOSPITAL BEDS/PARTS

Alco Sales Service, Co.……………………………… 69

74 | OR TODAY | APRIL 2018

Cygnus Medical………………………………… 9, 50-53 Healthmark Industries Company, Inc.……… 4 TBJ Incorporated…………………………………………… 5

SURGICAL

MD Technologies Inc.………………………………… 65 TIDI C-Armor………………………………………………… 6

SURGICAL INSTRUMENT/ACCESSORIES

Arthroplastics, Inc.…………………………………………17 C Change Surgical……………………………………… 13 Cygnus Medical………………………………… 9, 50-53 Healthmark Industries Company, Inc.……… 4 Key Surgical………………………………………………… 30

TELEMETRY

AIV Inc.………………………………………………………… 15 Pacific Medical…………………………………………… 39

TEMPERATURE MANAGEMENT

C Change Surgical……………………………………… 13 Cincinnati Sub-Zero…………………………………… 58 MAC Medical, Inc………………………………………… 67

WARMERS

Cincinnati Sub-Zero…………………………………… 58 MAC Medical, Inc………………………………………… 67

WASTE MANAGEMENT

MD Technologies inc.………………………………… 65 TBJ Incorporated…………………………………………… 5

WOUND MANAGEMENT

Tetra……………………………………………………………… 25

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