OR Today - May 2018

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OR TODAY | May 2018

contents features

SPD

A VITAL COLLABORATION

THE OR AND

42 THE OR AND SPD: A VITAL COLLABORATION It’s critical that OR personnel build strong relationships with other departments throughout the health care facility. But perhaps no partnership is as critical as the one between the OR and the sterile processing department (SPD).

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Peripheral nerve injuries can occur for many reasons, and a team approach helps prevent them during surgery. The perioperative team must understand proper positioning techniques to

After more than 30 years, Key Surgical continues to support sterile processing and OR departments with the end goal of positive surgical outcomes.

Dynamic Running Therapy is a step-by-step therapeutic method for confronting difficult feelings and circumstances in your life through movement.

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ensure the best possible outcome for the patient.

OR Today (Vol. 18, Issue #05) May 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.

For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. Š 2018

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contents features

PUBLISHER John M. Krieg

john@mdpublishing.com

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VICE PRESIDENT Kristin Leavoy

AORN SCRAPBOOK

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View our photos from the AORN Surgical Conference & Expo in New Orleans, LA

EDITOR John Wallace

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ART DEPARTMENT Jonathan Riley Karlee Gower Kathryn Keur

ACCOUNT EXECUTIVES Lisa Gosser

lgosser@mdpublishing.com Jayme McKelvey

jayme@mdpublishing.com Megan Cabot

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Linda Yoder

Creamy Chicken Tortellini Soup

SPOTLIGHT ON

RECIPE OF THE MONTH

ACCOUNTING Kim Callahan

DIGITAL SERVICES Travis Saylor Cindy Galindo Jena Mattison

CIRCULATION Lisa Cover Melissa Brand

INDUSTRY INSIGHTS

10 News & Notes 16 Experience Equips Experts Against Epidemic 18 Webinar Recap

WEBINARS Linda Hasluem webinar@mdpublishing.com

IN THE OR

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

NASHVILLE, TN August 26-28, 2018

18 Eastbrook Bend,

OUT OF THE OR 50 Fitness 52 Health 54 Nutrition 56 Recipe 59 Pinboard 60 AORN Scrapbook 62 Index

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INDUSTRY INSIGHTS

news & notes

AORN Syntegrity Inc., IMO Create Consolidated Surgical Scheduling Procedure List AORN Syntegrity Inc., provider of a perioperative documentation system, and Intelligent Medical Objects Inc. (IMO), the developer of a medical terminology solution for the management of medical vocabularies and software applications at health care organizations, have announced a technology partnership in conjunction with the launch of a new product, PeriopIT. PeriopIT combines AORN’s perioperative care expertise with IMO’s clinical terminology expertise to create a surgical scheduling solution that works behind the scenes in operating room scheduling systems and EHRs to improve patient outcomes and increase revenue.

As a surgical scheduling solution, enhanced with AORN Syntegrity, PeriopIT is mapped to health care code sets, aids in meeting regulatory requirements thus ensuring maximum reimbursement, accurate scheduling, and defining workflow efficiencies for the perioperative setting. It will enhance claims and reporting workflows, optimize communication and patient outcomes, improve procedure scheduling, and reduce operation and IT workloads.

“The combination of IMO and AORN technologies is exciting and just the innovative solution that surgery centers have been asking for,” said Frank Naeymi-Rad, PhD, chairman and chief executive officer of IMO. “Our combined PeriopIT solution will streamline workflows and ensure accurate codes for every in-patient and outpatient procedure.”

“We are proud to partner with IMO,” said Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, CEO/ executive director of AORN. “This partnership is a perfect evolution for Syntegrity and the result, PeriopIT, will provide practitioners and administrators with more flexibility and features while assisting to identify evidence-based inconsistencies in the delivery of quality care to the surgical patient.” •

10 | OR TODAY | MAY 2018

Ansell Introduces GAMMEX PI Glove-inGlove System Ansell has announced the launch of the GAMMEX PI Glove-in-Glove System, a pre-donned double gloving system that helps promote safer operating rooms by enabling faster and easier double gloving.

This system features Ansell’s new GAMMEX PI Hybrid as the outer glove, a blend of two synthetic materials where the comfort of polyisoprene (PI) meets the strength of neoprene. This is combined with the green-colored GAMMEX Non-Latex PI Underglove – a thin PI underglove – for quick and easy glove breach detection.

“Although the world’s leading professional surgical organizations recommend double gloving to reduce the risk of infections, studies suggest that many surgeons and OR nurses don’t heed these recommendations due to objections such as a lack of time, inconvenience, discomfort and challenges with tactility,” according to a press release announcing the GAMMEX PI Glove-in-Glove System. “Driven by innovation, GAMMEX surgical gloves are engineered to respond to minimizing such objections and improve double gloving compliance. With the outer and inner glove pre-donned and aligned at the fingers, GAMMEX PI Glove-in-Glove System does just that by enabling users to double glove in just one don. Without compromising on comfort, the world’s first double gloving system ensures peace of mind with the protection of double-gloving.” •

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INDUSTRY INSIGHTS

news & notes

Nihon Kohden Launches New Products at HIMSS18 Nihon Kohden has announced the patient-friendly, mobile-ready func- and a sampling frequency up to commercial launch of its NK-HiQ tionality.

4,000 Hz per channel for enhanced Wireless Patient Monitoring System, “Nihon Kohden has been the disease detection, diagnosis and a smart, secure data acquisition and leader in premium EEG technology clinical decision-making. Clinicians management platform that leverages for nearly 70 years,” said Constancan quickly montage, filter and Wi-Fi technology to provide safe tine. “We pioneered the world’s first annotate patient data to speed care continuous patient monitoring in the AC-powered EEG system, and we’ve delivery and improve workflow efhospital setting. With a suite of fully continued to deliver proven innovaficiencies. featured central station, bedside, tion ever since. The aireeg wireless In an environment that requires transport and wearable patient moni- EEG is the next step in this evoluincreased patient protection and tors, the system captures and mantion, offering clinicians a diagnostic care, aireeg uses true wireless (Wiages patient data from admission to platform that provides superior data Fi) technology, which delivers strong discharge, seamlessly throughout the quality to quickly identify a medical signal range throughout the hospiPROOF APPROVED issue, CHANGES NEEDED enterprise. The company showcased while still allowing a patient to tal, to give patients greater mobility its NK-HiQ systemCLIENT at HIMSS18 in be freely moved throughout a facilwithout sacrificing safety. In addition, SIGN–OFF: Las Vegas. ity. It offers capabilities unlike any proprietary Smart Camera switching PLEASE CONFIRM THATon THE FOLLOWING ARE CORRECT “We believe that wireless patient other the market today.” technology auto-detects patient locaLOGO PHONE WEBSITE to imADDRESStion and SPELLING monitoring is the future of health The NUMBER aireeg was designed seamlesslyGRAMMAR switches cameras care, and with our NK-HiQ system, prove clinical care and workflow by when a patient is transported between we are at the forefront of that fudelivering real-time EEG waveform hospital rooms. • ture,” said Dr. Wilson P. Constantine, access, best-in-class signal quality, TRIM 4.5” CEO of Nihon Kohden America.

“With NK-HiQ, care providers can leverage their investment in existing 802.11 infrastructure to keep patients safe and clinicians informed no matter patient acuity level or location in the hospital. Ultimately, we expect this advanced wireless system to give clinicians the data they need at the point of care to move into a new era of preventive and predictive health.”

Nihon Kohden also launched its aireeg WEE-1200 wireless electroencephalogram (EEG) system designed specifically for patient comfort and easy access to realtime patient data during long-term epilepsy monitoring, intensive care, and routine EEG environments. The platform – which was highlighted at Nihon Kohden’s HIMSS18 booth – offers clinicians and patients an EEG solution with

PROOF S

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TRIM 4.5”

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INDUSTRY INSIGHTS

news & notes

ASCA Comments on News Reports The leadership of the Ambulatory Surgery Center Association (ASCA), the country’s leading representative and advocate of ambulatory surgery centers, sharply rebuked both Kaiser Health News (KHN) and USA Today for a March 2, 2018, report about outpatient surgery, “As Surgery Centers Boom Patients Are Paying With Their Lives,” by Christina Jewett and Mark Alesia.

“KHN and USA Today have done a terrible disservice to their readers in their article about ambulatory surgery centers by failing to accurately and responsibly report the high-quality, high-value outcomes occurring in ambulatory surgery centers today,” said William Prentice, chief executive officer of ASCA. “By focusing their story on a relatively small number of tragic errors, while ignoring the overwhelming beneficial outcomes found in ASCs, they have created a false and misleading narrative about the safety and efficacy of outpatient surgery.”

The story focuses on approximately 260 adverse events that are alleged to have occurred as a result of care in ASCs over the past five years but fails to note that over that time ASCs safely performed more than 200 million procedures. By not putting the number of adverse events into context, this article misleads readers into thinking that ASCs have more adverse events than other sites of service, when they actually have fewer.

The implication that ASCs somehow pose a higher level of risk to the patients they serve is false and unsupported by data and the medical literature. •

12 | OR TODAY | MAY 2018

Encompass Group Introduces LongSleeve Scrub Top with Modesty Neck Panel Encompass Group LLC has introduced the Synergy Professional Apparel long-sleeve scrub top for OR settings. Barrier sleeves aid in reducing the dispersion of dead skin scales or squames into the OR and hospital air. Less skin exposure aids in reducing the skin-to-skin contact between patients and caregivers.

The new long-sleeve scrub top fulfills the AORN guidelines for surgical attire recommending the covering of arms. The top also features a little extra “modesty” coverage around the neck area.

Synergy Professional Apparel perfectly blends durability and value with a fashionable variety of styles and colors. All styles are made of Synergy fabric, a durable poly-rich blend that is comfortable, opaque and quick drying.

“We’re very pleased to offer this new scrub top for health care workers. The modesty neck is a great feature, and the long-sleeves are comfortable and provide increased safety for patients or residents and staff,” said Encompass Group’s Bridget Miklausich.

The new tops come in 14 colors and a range of sizes from XS to 5XL. Coordinating pants are available. •

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Halyard Health Upgrades ON-Q TRAC Patient Engagement Platform Halyard Health has announced the availability of ON-Q TRAC 3.0, the latest version of its online patient engagement platform allowing physicians to monitor, measure and track patients’ post-operative satisfaction and pain to improve the overall patient experience. ON-Q TRAC 3.0, along with Halyard’s full suite of pain management products, was recently on display at Halyard booth #6233 at the American Academy of Orthopaedic Surgeons (AAOS) 2018 Annual Meeting.

The new ON-Q TRAC 3.0 platform allows physicians to set pre-configurable threshold notifications, allowing for direct follow-up on specific care metrics that exceed providers’ acceptable recovery values including pain, sleep, functional activity and more. Additionally, ON-Q TRAC 3.0 includes capabilities for real-time alerts via text or email that can help physicians to better track key outcome data and patient feedback and provide opportunities for appropriate intervention to potentially reduce readmissions and lower opioid consumption. Studies show that increased physician to patient connectivity enhances patient satisfaction scores, helps improve outcomes and can boost reputation and referrals.

With ON-Q TRAC 3.0, physicians are also able to benchmark and compare their patients’ progress against other patients and physician practices around the country in the ON-Q TRAC database. This enhanced analysis provides physicians with deeper insights into how their patients’ progress compares to other facilities so they can quickly and efficiently modify protocols and treatment plans for improved outcomes.

Additional ON-Q TRAC 3.0 analytical upgrades include: • New chart drill-down functionality allows providers to easily analyze outcomes at the individual patient case level.

• Resource center featuring Halyard patient education materials, which can be delivered directly to patients via a web-browser or smartphone.

• Ability to compare outcomes between pain management modalities to evaluate the effect of different treatments to ensure optimal patient recovery. •

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INDUSTRY INSIGHTS

news & notes

AIV Meets ISO 13485:2016 Certification Upgrade Deadline AIV has implemented the ISO 13485:2016 certification one year ahead of the March 2019 deadline. It is required that all ISO 13485 companies be certified to the newest standard by March 2019. BSI issued AIV’s certificate on February 13, 2018 AIV’s quality and regulatory department conducted a detailed review of the company’s entire quality management system, including the quality manual, quality systems procedures and applicable forms. All new requirements outlined in ISO 13485:2016 were added to the quality management system prior to AIV’s January 2018 re-certification and transition audit.

According to the International Organization for Standardization, ISO 13485:2016 specifies requirements for a quality management system where the organization needs to demonstrate the ability to provide medical devices and related services that consistently meet customer’s needs and regulatory requirements. The new ISO 13485:2016 standard requires the application of a risk-based approach to quality management systems. Some of the updates from the ISO 13485:2003 standard include design control and development changes, product handling and storage, the evaluation of safety and performance of products, and the associated training of the end user.

AIV was initially certified to ISO 9001 and upgraded to ISO 13485:2003 on March 29, 2006. Choosing to implement ISO 13485 was a requirement for the company to address the European Medical Device Directives, regulations and responsibilities, and for the

14 | OR TODAY | MAY 2018

safety and quality of medical devices. It also ensures the consistent design, development, production and delivery of medical devices and replacement parts manufactured by AIV. The transition to the newest quality standard included the review of AIV’s entire quality management system, including the Quality Manual, Quality Systems Procedures and applicable forms which provide evidence that documented procedures are being followed.

Auditors were impressed with the maturity of AIV’s quality system and manuals and felt AIV’s technicians knew their jobs. The auditor felt that she could perform the explained tasks with the work instructions and little guidance.

Renee Gould with Global Regulatory Compliance, AIV’s internal auditor, commended the achievement saying, “the AIV team is passionate and focuses on meeting customer and regulatory requirements. This is demonstrated by AIV planning, implementing and achieving ISO 13485:2016 certification one year prior to the deadline. This is a significant achievement. Congratulations!”

AIV’s ISO 13485:2016 Quality Management System complies with the requirements for the following: The design, manufacture, service and distribution of ultrasound and toco dynamic fetal monitor transducers, components for infusion pumps, pulse oximeters and fetal monitor transducers, patient monitoring devices and ventilation devices; the service only of infusion pump, pulse oximeters and fetal monitor transducers. •

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Welch Allyn Connex Technology Showcased at HIMSS Conference Hill-Rom debuted enhanced workflow efficiency and security features for its Welch Allyn Connex vital signs monitoring portfolio at the HIMSS Conference. The devices now integrate secure access technology from Imprivata, a healthcare IT security company, to enable stronger protection of patient data collected or stored on Connex devices used in EMR-connected workflows, while providing clinicians a faster, easier way to access or update patient data.

Medical devices commonly require a user to log in to gain entry. With this new technology integration, Connex vitals monitoring devices have the ability to read a clinician’s hospital security badge via barcode or RFID, offering one-step device access at the bedside. This faster, more efficient log-in to the device helps clinicians move quickly to their primary focus – patient care – while also protecting data integrity into the EMR. The technology enhancements to Welch Allyn’s vitals portfolio also include the ability to restrict device access to just those people who need it, which means less potential for data to be compromised, either by accident or by design.

Industry observers suggest that the average cost of a health care data breach is $2.2 million per incident, costing the industry $6.2 billion over two years. Failure to properly secure medical devices can lead to a myriad of problems for health care organizations, ranging from data integrity and availability concerns to compliance and patient safety implications. Connex vital signs monitors that are integrated with Imprivata technology, along with the existing Connex security and encryption features, can help improve data security by assuring that EMR users are properly authenticated.

These technology enhancements for the Connex family of vital signs devices debuted during the 2018 Healthcare Information and Management Systems Society (HIMSS) conference, which features Hill-Rom’s complete solution set across the care continuum. Connex vital signs devices are designed to encrypt the data they exchange and support secure authentication in accordance with industry best practices. •

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INDUSTRY INSIGHTS

Experience Equips Experts Against Epidemic

By Rodrigo Garcia, APN, MSN, CRNA, MBA remember it well. A late added surgical case was taking longer than expected and melancholic tones from the ECG machine were working in this cooled room to facilitate a new kind of anxiety. This day my thoughts would be different from the norm and from the coming moment on I would never be the same.

I

The last few weeks had been spent trying to “ween” off the prescription medication I received after my shattered ankle repair three months prior.

Doing “the math” as a part of my pain treatment has become a new norm.

My life was now being planned around my dosing cycle which was being directed by the ability to secure yet another prescription. At the time, opioid prescriptions were being written more generously and with less regulatory oversight. “As needed” became a new mantra and my growing physical dependency, free flowing supply and false sense of security equated “as needed” to “always needed.”

I was educated and far from oblivious to the dangers of addiction and the impaired provider. I was not getting enjoyment out of taking the medication. I was productive and well respected at work. It was a legal prescription from my physician. I had a great family and many friends. And, I ONLY took the medication because

16 | OR TODAY | MAY 2018

I needed them to feel normal. I knew what an addict looked like and that was not me.

This particular day I had already done the math several times and was aware that I would soon be out without any “plan” to quell the impending withdrawal. The physical pain had subsided to tolerable levels quite some time ago, but without the prescription medication I felt miserable, actually it was debilitating on every front (physical, emotional, mental, psychological).

My calculations were correct. I had run out of medication and would soon feel the paralyzing effects.

The physical effects were tolerable, at least initially. However, the anxiety, anticipation and mind racing was immediately unbearable. It was near the end of the case and I could feel the writhing discomfort and self-loathing begin to take its hold as the withdraw settled in and self-shame took over. Maybe it was self-preservation, perhaps desperation. It may have even been maladaptive rationalization. It was likely all.

Whether over or under thinking, I began contemplating options to solve my growing angst. As I became consumed by pain, discomfort and fear, I looked around my work environment and realized the “solution” was always surrounding me. It was apparent that the “waste medication” could be used to ward off the evils of withdrawal.

Moving forward, it would be used to

Rodrigo Garcia, APN, MSN, CRNA, MBA, CEO, Parkdale Companies-Parkdale Center for Professionals & Parkdale Solutions

bring strength to my failing body and comfort to my troubled mind. From this moment on, I would never see my work world the same way again.

Someday, this experience and growing knowledge would become an incredible asset, but not before going through a tumultuous personal and professional hell.

As I continued to move through the next several days, my observations would lead me to ask myself, “Has it always been this way?” I noticed anesthesia carts unlocked, unattended powerful medication, automated dispensing machines logged open, questionable waste medication witnessing, improper controlled substance disposal, loose pharmacy parameters, blind trust, and poorly written or implemented policies pertaining to the impaired provider. What was clearly apparent was that while the outside world was talking about, and feverishly tightening, prescribing and dispensing regulations to address the opioid epidemic, hospitals across the country had become unwitting participants in the largest drug heists on record, to the tune of 300 billion dollars a year.

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My fall from that point was not a unique story. The arduous climb back up to health and success, however, required support and assistance from many people. Thanks to the involvement of hospital administrators, skilled treatment providers, regulatory agencies and family my story has a positive outcome.

Today, my wife, business partner, highly skilled practitioners and staff have come together to form a professionals-only addiction treatment center called Parkdale Center

for Professionals. Those combined talents, along with some additional forces, have given way to using our new-found experience and knowledge to address the growing epidemic of hospital diversion and the impaired provider. Parkdale Solutions is forging new ground with a cutting-edge program called Healthcare Experts in Loss Prevention (H.E.L.P.).

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news & notes webinar

‘Cavitating’ Webinar Delivers Knowledge, Tips Staff report he OR Today webinar series continues to deliver valuable content in 2018!

T

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

This multifaceted webinar was a reflection of the audience who works 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-understand

18 | OR TODAY | MAY 2018

images as it illustrated how and why waves converted to energy for cleanultrasonic cavitation is so important. ing was very helpful. … I have worked More than a 100 health care in surgery and/or SPD for almost 40 professionals attended the live years and this was a great source of presentation and more have viewed information for new as well as seait online on the OR Today website soned staff,” wrote K. Johnston, nurse and on YouTube. educator SPD. Attendees shared positive feedback “This was a very informative regarding the webinar and the OR webinar. The presenter had excelToday series in a post-webinar survey. lent knowledge of the material and Some of the most experienced prowas interesting to listen to,” shared S. fessionals plan to share the recorded Petruzzi, nurse manager. presentation with their staffs.

“I was able to walk away from the “The OR Today webinar by Ultra webinar with more knowledge and Clean Systems was good for all levels helpful tips after this. I highly recomof experience in the SPD. I have worked in ster“The webinars offered by OR Today ile processing for 26 years and are always time well spent! Thank you.” this presentation reinforced some of – A. Poe, Clinical Nurse Specialist. the things I knew and provided me new knowledge on updated process mend this to any health teams,” shared requirements. I would love to give this L. Grant Jr., sterile processing. in-service to all my staff,” L. Borg“Thank you for the very interestmann, sterile processing supervisor, ing and informative webinar on ulsaid. trasonic cleaning. It was captivating,” “The demonstration of the sound L. Rogala, CRCST, said in a survey.

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“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 more information about upcoming webinars and recorded webinars visit ortoday.com/upcoming-webinars.

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MAY 2018 | OR TODAY |

19

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

SPD AND CERTIFIED SURGICAL TECHNOLOGISTS

Is it beneficial to staff sterile processing departments with surgical technologists? Will this increase patient safety and decrease case delays? Can you tell me if certified surgical technologists have a role in your sterile departments?

A: Surgical techs have their place. Several of my sterile processing techs have gone on to become

surg techs and RNs. However, sterile processing is a career choice in and of itself and should be respected and promoted as such. The financial remuneration should be equal to the job responsibility. Sterile processing techs and the work they perform “behind the scenes” is vital to a smooth running OR. I consider sterile processing techs to be the “first assists” to the OR. We need to be one step ahead of the OR just to keep up. Sterile processing techs are on the same team and should be granted the respect of being included in all decisions in the daily running of the OR. Invest in your sterile processing techs and treat them no differently than you would a surg tech or RN. They, we and I have earned it. Pay them well, certify them and offer continuing education. A great sterile processing tech is worth their weight in gold. Many of my best employees have come from environmental services and food services. They are grateful for a different path and want to learn more and do more. Tap into that.

A: While surgical techs may know their instruments well, there is much more to our profession

than the instruments. Your money would be better spent by paying your sterile processing techs more, certifying them and including them in every aspect of “Surgical Services.” We are critical in the fight for infection control (as is environmental services too). Here at our facility, new OR nurses and scrub techs must spend days in the sterile processing department to get a better understanding of how vital our working relationship is to surgical services and how best we can work together as a team and make no mistake, we are a team. Every day I meet with the OR director, the OR clinical manager and materials management. We go over the OR schedule, for three days out, to review instrument needs, conflicts in equipment needs and incoming loaners. We are well respected and included in decisions that affect the day as well we should be. Truthfully, every director of surgical services would be smart to spend one whole day in SPD and I implore you to do so. I apologize if I sound like I am preaching, that is not my intent. Again, your money would be better served in sterile processing.

A: That is well said and so true.

ASK YOUR QUESTION AT THEORNATION.COM

20 | OR TODAY | MAY 2018

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IN THE OR

market analysis

Endoscopes Staff report espite multiple appearances on annual lists of technology hazards the past several years, endoscopes continue to be an important and valuable health care tool.

In fact, the importance of these devices has prompted a laser focus on making sure they are cleaned correctly and continue to be available for health care providers.

A report from Market Research Store forecasts continued growth for the endoscope market.

“The global endoscopy devices market is estimated to be $30.1 billion in 2014 and is poised to reach $47.6 billion by 2022, growing at a compound annual growth rate (CAGR) of 5.90 percent from 2014 to 2022,” according to Market Research Store. “Some of the key factors driving the market growth are rising preference for minimally invasive surgeries, technological advancements and aging population.

Whereas factors such as lack of skilled professionals and high investment costs for endoscopic equipment are restraining the market growth.

Growing economic conditions, high

D

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income, developing health sectors and a large consumer base in emerging countries like India and China will drive the endoscopy device market opportunities.”

Another report also predicts continued market growth.

“The global endoscopy devices market is a fast growing market with huge potential for growth due to rapid technological advancements and large sum of public and private investment in medical infrastructure and health care,” according to Occams Business Research. “The global endoscopy devices market was valued at $31 billion approximately in 2015, and it is estimated to cross the $47 billion mark by 2022 with a healthy CAGR of around 6 percent for the forecast period 2015-2022.”

BCC Research also projects continued growth for the endoscope market.

“The global endoscopy device market is expected to grow from $32.5 billion in 2015 to roughly $45.2 billion by 2020, with a compound annual growth rate (CAGR) of 6.8 percent for the period of 2015-2020,” according to BCC Research.

MarketsandMarkets is another research group that predicts growth for the endoscope market.

“This market is expected to reach $33.6 billion by 2020 from $23.8 billion in 2015, at a CAGR of 6.1 percent,” MarketsandMarkets reports.

The cleaning of endoscopes is also a huge market.

“The global automated endoscope reprocessors market estimated to be worth $740.6 million in 2015, is expected to increase at a compound annual growth rate of 7.2 percent through 2024,” according to Persistence Market Research.

Endoscope cleaning is a part of the larger medical device cleaning market.

According to a Data Bridge Market Research market report, the global medical device cleaning market accounted to $1.54 billion in 2016 and is expected to expand at a CAGR of 5.3 percent during the forecast period of 2017 to 2024.

“The rise in the global medical device cleaning market is owing to rapid increase in geriatric population and rise in incidence of hospital-acquired infections (HAIs) and chronic diseases,” Data Bridge Market Research reports.

MAY 2018 | OR TODAY |

23

IN THE OR

product focus

Capital Medical Resources

Endoscopic Electrosurgical Cords Capital Medical Resources offers a full line of reusable/disposable and monopolar/ bipolar/tripolar endoscopic electrosurgical cords. These high-frequency, RF cords use electrical current to cut, coagulate, dissect tissue and help prevent blood loss in a variety of surgical and laparoscopic procedures. The high-quality cords are compatible with a wide-variety of laparoscopic and electrosurgical instrumentation and generator combinations including Stryker (Capital Medical Resources is a Stryker-recommended supplier for the recently discontinued 250-040-011, 250-040-012, 250-040-016 models), Storz, Wolf, Aesculap, Conmed, Kirwan, Erbe, Valleylab, Bovie and more!

The cords come in 10-foot length, are nonlatex and are made in the USA. Disposable, single-use cords are sterile and come in a box of 10. Reusable cords are non-sterile, sold indiviually and are autoclave compatible. •

24 | OR TODAY | MAY 2018

Cygnus Medical

Airtime Instrument Channel Dryer Properly dried endoscope 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. They are 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 shut off the Airtime pump and alert the user of a potentially clogged channel.

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

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IN THE OR

FUJIFILM Medical Systems U.S.A. Inc.

product focus

ELUXEO

FUJIFILM Medical Systems U.S.A. Inc.Endoscopy pushes the boundaries of innovation with ELUXEO, the company’s next-generation endoscopic video imaging system. Featuring 4-LED multi-light technology, ELUXEO was developed to achieve optimal results in illumination through its special light observation modes, Blue Light Imaging (BLI) and Linked Color Imaging (LCI). The system is equipped with extended system life expectancy and an intuitive user interface for an enhanced experience. With ELUXEO, Fujifilm is setting a new standard in image enhanced endoscopy.” •

Xenocor

Xenoscope

OLYMPUS

EVIS EXERA III GIF1TH190 Gastroscope The EVIS EXERA III GIF-1TH190 gastroscope is designed for image-guided therapy with a 3.7 mm instrument channel. The scope’s HDTV image quality is a first for a single-channel therapeutic gastroscope, while the addition of NBI capability may aid in the interpretation of mucosal morphology, vascular patterns and blood vessel appearance in patients with Barrett’s esophagus. The slimmer 10.0 mm distal end is smaller than the predecessor. For further efficiencies, a new connector design minimizes the effort required for setup prior to and in between cases and eliminates the need for a water-resistant cap. •

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The Xenoscope is a single-use, sterile, and lightweight HD scope that provides exceptional image quality at a fraction of the cost of current systems on the market. It features pre-white balanced LED lighting for convenience and simplicity in use. Offered terminally sterile, the device also eliminates the risk of disease transmission from patient cross contamination. The scopes are available in 10mm with 0-degree and 30-degree options. With its HD imaging, the Xenoscope brings significantly improved value with lower-cost patient care. It interfaces with our Xenobox, with industry standard USB and HDMI connectors, plug-and-play versatility, capable of displaying images on a variety of HD monitors, tablets, laptops and smartphone devices. Its unique design eliminates fogging, has low temperature LED illumination that virtually eliminates burn risk, enhancing patient safety. Being terminally sterile, it reduces operating room turnover time. The convenience, cost savings and patient safety benefits of the Xenoscope make it an invaluable addition to every surgical suite. •

MAY 2018 | OR TODAY |

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IN THE OR

continuing education

28 | OR TODAY | MAY 2018

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CE416

IN THE OR

continuing Proper Positioning Helps education Avoid Upper Extremity Nerve Damage During Surgery Nancymarie Phillips, PhD, RN, RNFA, CNOR(E) magine that you are working in the OR when the arm board on which your patient’s left arm is secured falls during repositioning. The team immediately supports the patient’s arm, and the operation proceeds uneventfully. However, the patient later complains of left arm numbness and pain.

An electromyography/nerve conduction velocity (EMG) study shows acute denervation of the left C5-C6 nerves. The branches affected include the ulnar, medial, axillary, and radial nerves. The damage to the nerves in the affected arm involves both motor and sensory nerves from the nerve root C6.1

I

Peripheral nerve injuries can occur during any type of surgery. Men ages 50 to 75 are at higher risk. These injuries can occur for many reasons: faulty equipment, improper positioning, pressure from personnel or equipment, and sometimes for no apparent reason at all.2 A team approach helps prevent peripheral nerve injuries during surgery. The perioperative team caring for surgical patients before, during, and after surgery and other invasive procedures, such as endoscopy, must understand proper positioning techniques to ensure the best possible outcome for the patient.

How often do these injuries occur?

We don’t know for sure because patients don’t report some of them. Injuries that are reported may be treated, referred to a specialist, or resolve by themselves over time. Patients with reported injury complain of motion problems with the biceps and sensory tingling in the thumb and index finger.2 Extreme cases involve WWW.ORTODAY.COM

the majority of the forearm associated with the radial nerve.

The American Society of Anesthesiologists (ASA) assembled a task force of anesthesiologists, nurse anesthetists, anesthesiology assistants, perioperative nurses, surgeons, and emergency medicine physicians to develop a practice advisory. It describes recommendations for pre- and postoperative assessment, positioning, padding, and equipment.

Upper extremity recommendations are summarized below.2

How Do These Injuries Occur?

The five primary mechanisms for perioperative neuropathies are stretch, compression/pressure, generalized ischemia, metabolic comorbidity, and surgical trauma. As little as a 10% to 15% elongation of a peripheral nerve is enough to cause important alterations in vital physiological processes, compromising the condition of the peripheral nerve.2 Patients may arrive for surgery with pre-existing metabolic comorbidities and subclinical neuropathies. The metabolic comorbidities that can play a role in peripheral neuropathies include diabetes, pernicious anemia, alcoholic neuritis, atherosclerosis, drug exposure, heavy metal exposure, and multiple sclerosis.2,3

Patient Assessment The position for surgery is determined initially by the procedure to be performed, the surgeon’s choice of approach, and the anesthetic considerations. In addition, the surgical team as a whole needs to consider the patient’s preoperative history and physical examination.1,2 ,3 This usually includes the patient’s age, height, weight, general health status, activity level, mobility restrictions, cardiopulmo-

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

Goal and objectives The goal of this continuing education program is to provide nurses with information about the proper positioning of the patient undergoing surgery and other invasive procedures with an emphasis on avoiding intraoperative nerve damage to the upper extremities. After studying the information here, you will be able to: • Identify areas of the upper extremities at highest risk for developing position-related nerve damage during operative or other invasive procedures • Discuss the collaborative efforts of the perioperative nurse, anesthesia provider, assisting personnel, and surgeon required for patient positioning • Describe interventions required to avoid intraoperative nerve injury • List five primary mechanisms for perioperative neuropathies • Describe the most common upper extremity injuries

MAY 2018 | OR TODAY |

29

IN THE OR

continuing education nary status, pre-existing diseases, neurological status, presence of implants, and known areas of discomfort.

Certain pre-existing risk factors may affect positioning strategies, including obesity, paralysis, history of previous upper limb fracture, and advanced age. Many positions can be tested before surgery when patients

are awake.2 The anesthesia provider should gently abduct, adduct, flex, extend, and rotate the upper extremities into the positions the patient may experience, checking for resistance and pain. It is essential to check all positioning equipment, such as arm boards and supports, for proper functioning.3

Avoiding Upper Extremity Injuries2 Preoperative Assessment • When appropriate, it’s helpful to ascertain that patients can comfortably tolerate the anticipated operative position.

Upper Extremity Positioning • Arm abduction should be limited to 90 degrees in supine patients; patients who are positioned prone may comfortably tolerate arm abduction greater than 90 degrees.

• Arms should be positioned to decrease pressure on the postcondylar groove of the humerus (ulnar groove). When arms are tucked at the side, a neutral forearm position is recommended. When arms are abducted on arm boards, careful supination or a neutral forearm position is acceptable.

• Prolonged pressure on the radial nerve in the spiral groove of the humerus should be avoided.

• Extension of the elbow beyond a comfortable range when in supination may stretch the median nerve.

Additional padding to protect the elbow may be needed, and care is taken not to use tight arm board straps.3

Protective Padding • Padded arm boards may decrease the risk of upper extremity neuropathies.

• The use of an axillary roll in

30 | OR TODAY | MAY 2018

laterally positioned patients may decrease the risk of upper extremity neuropathies.3 An axillary roll is placed at a right angle to the body below the arm pit to minimize body weight pressure on the lower shoulder.3 • Padding at the elbow may decrease the risk of upper extremity neuropathies.

Equipment • Properly functioning automated blood pressure cuffs on the upper arms do not affect the risk of upper extremity neuropathies.

• Shoulder braces in steep headdown position may increase the risk of neuropathies.

Postoperative Assessment • A simple postoperative assessment of extremity nerve function may lead to early recognition of peripheral neuropathies.

Documentation • Charting specific positioning actions during the care of patients may improve care by helping practitioners focus on relevant aspects of patient positioning and by providing information that leads to improvements in patient care.

Preventing Harm to the Upper Extremities Brachial plexus and ulnar neuropathies are the most common upper extremity injuries. Some brachial plexus injuries not related directly to positioning include those caused by median sternotomy and retractor use in cardiothoracic procedures and those related to brachial plexus blocks by the anesthesia provider.3 Shoulder braces have been implicated in numerous brachial plexus injuries in supine patients and are discouraged. If possible, avoid using shoulder braces by using a secured vacuum pack (beanbag) to hold the patient in place on the operating bed instead.3 Before placing a patient on a beanbag, the surface must be completely soft and smooth with gel padding between patient contact points and the bag. When vacuuming the air from the beanbag, the edges are folded to conform to the patient’s body contours as the bag becomes rigid. If shoulder braces must be used, they should be placed over the acromion processes and not over the muscles and soft tissues near the neck.

The braces must be padded adequately to prevent pressure between the metal brace and the patient’s shoulder bones.

Shoulder braces can be used in combination with the beanbag to reduce body weight pressure on the shoulders.

Shoulder braces should not be used if the arms are abducted on arm boards.3 Ulnar neuropathies are the most reported neural injuries.2 The ulnar nerve passes around the medial epicondyle of the humerus at the elbow and under the retinaculum of the cubital tunnel. The nerve runs very close to the surface at the elbow, which leaves it vulnerable to injury when the pressure of the arm weight is not proportionate. Perioperative ulnar nerve injury often is ascribed to malposition of the elbow, with the ulnar nerve being compressed on a hard surface during surgery or stretched in some fashion. Arm boards have viscoeleastic foam padding or gel pads. Gel pads are WWW.ORTODAY.COM

IN THE OR

continuing education

preferred because they offer alternating surface pressure and decreased interface tension.3 Controversy exists in the literature on whether arms should remain neutral, pronated (palm face down), or supinated (palm face up) when the patient is supine. Pronation is not recommended in the current literature, because it causes a stretch effect over the full length of the brachial plexus from the shoulder distally to the ulnar nerve. Supination causes pressure over the elbow where the ulnar nerve crosses the bony olecranon. Generally, when the patient is supine, a neutral position is recommended as long as the position does not place direct pressure on the ulnar nerve at the elbow. If using arm boards for a supine patient, they should not be abducted more than 90 degrees away from the body to prevent injury to the branches of the brachial plexus.2,3 Neutral position causes the palms to face the sides of the body naturally.

When tucked at the sides, the arms should be secured and padded in neutral position (palms facing the body) to ensure there’s no pressure on the medial epicondyle from the side rail of the OR bed. To prevent extreme pressure, the drawsheet used to secure the patient’s arms at the sides should be tucked only under the patient’s body and not under the edges of the mattress.3 Tucking the sheet under the mattress pulls the arms posterior and can cause additional stretch on the brachial plexus and possibly the cervical plexus in the obese patient.

The arms are also more likely to droop and be compressed over the edge of the bed, injuring the radial, ulnar, or median nerves.3 Care is needed to avoid securing the draw sheet so tightly that the elbow becomes hyperextended.

A curved protective shield, a “sled,” should be positioned over each tucked arm at the level of the elbow.3 Because the patient’s body is fully draped durWWW.ORTODAY.COM

ing surgery, the arms are not visible, and the sleds offer an extra measure of protection. The sterile team is advised to avoid leaning on the patient’s arms during the surgical procedure. The pressure of a sterile team member’s body weight can cause significant nerve injury. Bed-mounted retractors are sometimes used and secured to the side rails next to the patient’s body.

The upright post of the retractor can press against the patient’s arm and cause injury when sleds are not used.

Positioning, however, may not be the only cause of upper extremity neuropathies. Tourniquets are implicated in some upper extremity nerve injuries. Extreme pressure settings can cause a crush injury or complete transection of the nerves in the upper arm. The tourniquet should be of the correct size for the extremity and positioned around the fleshy portion of the biceps. 4 Two layers of Webril or stockinette under the tourniquet serves as minimal padding and should be applied smoothly, without folds and wrinkles, which could cause pressure over a nerve or other tissue of the upper arm. Tourniquets are contraindicated in cases of infection or malignancy in the limb, vascular access ports, past history of deep vein thrombosis, peripheral vascular disease, rheumatoid arthritis, and skin grafts.3 A correctly applied tourniquet provides the sterile team with a bloodless field for the surgical procedure.

The duration of tourniquet inflation for the upper extremity should not exceed 60 minutes.3,4 The tourniquet pressure and duration of use should be recorded in the patient’s record by the anesthesia provider and the circulating nurse.3,4 Radial and median nerve injuries are much less common.5 Damage to the radial nerve is usually due to prolonged pressure when the radial nerve spirals around the humerus when the hand is malpositioned, especially when the hand is pronated. While

there have been reports of median nerve injuries during surgery, the incidence is very low.

Considerations for Safe Upper Extremity Positioning The ASA Practice Advisory says that prone patients may tolerate abduction greater than 90 degrees, but care providers should exercise caution in patients with pre-existing thoracic outlet syndrome, which is not always known.2,5,6 The elbows should neither flex more than 90 degrees nor hyperextend, or “straighten” more than the patient is comfortable with or when resistance is felt. The final resting position of the arms will resemble upright goal posts with flexion at the elbows and the hands naturally pronated. The arm position is sometimes called “diver’s posture.”3 A prone-positioning device decreases chest compression and prevents increased intra-abdominal pressure over the vena cava and supports the patient’s upper body weight.3 Chest rolls should be used bilaterally if a prone positioning frame is not used.

The chest rolls should extend from the anterior shoulders at the clavicles to the anterior portion of the iliac crests.3 The pressure is off the abdomen, and the chest excursion is not hindered.

The full body weight of the patient should not be supported by the arms, which would cause extreme pressure over the ulnar area and the glenoid fossa. Positioning the prone patient’s arm requires anterior circumferential rotation of the glenoid capsule at the shoulder.2,3 The arms cannot be directly abducted into this position without the risk of dislocation of the shoulder and glenoid stretch injury.

A study using awake, asymptomatic volunteers evaluated the impact of various arm and neck positions on the upper quadrant nervous system by measuring the range of motion that is achieved before pain occurs in the supine position.2 MAY 2018 | OR TODAY |

31

IN THE OR

continuing education

The Role of Tourniquets Tourniquets often are used in extremity surgeries to decrease blood loss and to increase visibility for the surgeon. Before the tourniquet is inflated, the operative extremity is elevated, and then exsanguinated by wrapping it from the distal end and working proximally with a flat elastic (Esmarch) bandage to minimize the risk of thrombosis.

According to AORN Guidelines for Perioperative Practice, average adult pressure settings for upper limbs range between 200 mmHg and 250 mmHg, and 300 mmHg and 350 mmHg for lower limbs. If the tourniquet is used at the ankle, the pressure is reduced to 325 mmHg.4 The 2015 AORN Guidelines for Perioperative Practice state that the accepted time for tourniquet inflation is 60 minutes for an upper extremity and 90 minutes for a lower extremity (with 75 minutes for a pediatric lower extremity). The anesthesia provider and circulating nurse need to notify the surgeon of tourniquet inflation time at routine intervals. If prolonged tourniquet times are anticipated, it is recommended to deflate the tourniquet for 15 minutes and then re-exsanguinate the extremity and reinflate the tourniquet each hour. The patient can experience irreversible damage at three hours duration.4 Lack of circulation stops delivery of oxygen and nutrients, as well as the removal of carbon dioxide and other metabolites, such as lactic acid.

Ischemia can damage neuromuscular and neurovascular nerve cells serving the extremity. Improper tourniquet placement can cause extremity nerve injury.4 If a tourniquet is placed such that it compresses a nerve between the tourniquet edge and a firm surface (bone), the inflation pressure can cause compression injury to the nerve. The team member placing the tourniquet is documented and must have knowledge of safe placement.4

32 | OR TODAY | MAY 2018

The findings suggested that: • Adding fixation (as in shoulder braces) significantly reduces range of motion even when braces are positioned correctly. If shoulder braces must be used, placing a beanbag under the lower area of the body can help unload the pressure against the braces. The pressure of braces should be controlled and monitored regularly.

• Simultaneously adding positions that load the nervous system can cause a greater impact than that of each individual position. An example would be abducting the arm, flexing the head away, and supinating the arm at the same time. This motion impacts both the cervical and the brachial plexus.

• Similarly, relaxing a neighboring region provides a neutralizing effect and allows for unloading the nervous system.

• Patients differ widely in their reactions to elongation of the nerve bed, possibly caused in part by pre-existing subclinical neuropathy.

Triggering a pre-existing subclinical neuropathy is considered a possible mechanism for development of perioperative ulnar neuropathy.

This has implications for both prevention of injury and medicolegal justification.

Patients positioned in the lateral decubitus, thoracotomy, or nephrectomy positions should have an axillary roll at a right angle under the dependent thorax just below the axilla.3 The axillary roll should lift the thorax at the rib cage and help prevent compression of the dependent neurovascular bundle of the shoulder.

Care is taken not to cause pressure to the lateral breast tissue.3 A pillow should be used to support the head, keeping it in line with the cervical spine. This neutral position helps minimize stretching on the dependant brachial plexus. The lower arm

should be positioned at an angle of less than 90 degrees. The upper arm should be placed in a well-padded elevated holder and positioned so as to minimize stretch on the brachial plexus. The upper arm-positioning device causes the arm positioning to look like the wings of a biplane and is often called an “airplane” arm board.3

Planning Intraoperative Care As with any intervention, the first step is assessment. Many of the factors to assess have been listed in the “assessment” section of the anesthesia record. With the risk factors in mind, the anesthesia provider checks the patient for range of motion and positions of discomfort that may be encountered during surgery. Communicate with the patient about any positioning concerns he or she may have.

Develop the positioning plan in conjunction with other members of the surgical team. There obviously must be a plan for patient positioning, but the perioperative team also must plan for additional padding, supports, and personnel to help move and position the patient, and have extra sterile drapes, if needed. Concerns about the patient’s physiology and surgical site exposure are coordinated between the anesthesia provider and the surgeon.3 Proper planning helps ensure the patient’s comfort and safety, and having everything ready reduces the time the patient must be anesthetized.

Implementation is a continuation of the planning step. The patient’s individual plan should be carried out in a smooth and timely manner. Coordination with the entire team, including the circulating nurse, surgeon, and the anesthesia provider, is critical to ensure that the patient is positioned optimally.

All positioning aids and padding should be applied, and the patient should be secured so that unintended movement will not occur later. A transport cart should be available for immediate use throughout the surgical procedure for WWW.ORTODAY.COM

IN THE OR

continuing education

prone and lateral patients in the event of a physiologic emergency, such as cardiac arrest or an emergency requiring the patient to be repositioned supine for treatment.3 Evaluation of the patient should be ongoing throughout the surgical procedure, with a final assessment at completion. Unlike alterations in skin integrity, nerve injuries are not apparent immediately. The patient can be assessed for proper positioning during the procedure, but evaluation of nerve function must wait until the immediate postoperative period. The postanesthesia unit nurses will continue the assessment process and evaluate the outcome of the surgical position.3 Perioperative documentation should include the nursing diagnosis; for example, “risk for peripheral sensory alteration,” and an appropriate goal or expected outcome statement, such as, “The patient will maintain normal peripheral sensory integrity” or “The patient is free from signs and symptoms of injury related to positioning.” AORN has developed a validated perioperative nursing vocabulary, known as the Perioperative Nursing Data Set for use in documenting perioperative nursing activities in patient care that is compatible with electronic heath records systems.7 The PNDS has been the accepted standard vocabulary since 1999. It incorporates the nursing process and identifies the patient care domains associated with safety, physiological responses, behavioral responses, and the health systems’ responses to surgery.

If a patient complains of a neurological deficit before, during, or after surgery, the perioperative nurse must report and document it. Be sure that the specific sensory or motor deficits, time of onset, and any subjective sensations, such as stinging, burning, pain, or sharpness, are documented and reported to the anesthesia provider and the surgeon.3 Neurology should be consulted as soon as possible to WWW.ORTODAY.COM

assess the patient and start treatment, if indicated.

Two Preventable Positioning Injuries

Grading of Peripheral Nerve Injuries

A 45-year-old woman with an L1-L3 spinal giant cell tumor presented for tumor embolization to interventional radiology. The procedure was done under general anesthesia with her arms abducted to 120 degrees and her elbows bent at 90 degrees. The procedure lasted four hours in this position.

Peripheral nerve injuries can be graded based on the degree of injury. Two systems of grading nerve injuries are used in neurological practice based on the ability of the nerve injury to go into remission. According to John Henry Seddon, who published the basic types of peripheral nerve injury in 1943, there are three grades, with grade 1 being the least severe and grade 3 being the most severe. This grading system assesses the prognosis for each grade of injury. The higher-grade injuries are least likely to resolve.3 A grade 1 (neurapraxia), nerve injury is a response to blunt force or compression when there is a temporary dysfunction but only slight evidence of demyelination without nerve degeneration.

This occurs, for example, when crossing the legs for too long a time or in motor paralysis that follows excessive pressure from a pneumatic tourniquet. Sensation remains intact to the affected area.3 In a grade 2 (axonotmesis) nerve injury, destruction of nerve axons occurs, including the myelin sheath, but without damage to the supporting matrix. In this kind of injury, symptoms occur distal to the injury, but function can be restored eventually through nerve regeneration. This kind of injury is caused by interrupted endoneural blood supply or hypoxia.3 A grade 3 (neurotmesis) nerve injury is defined as a crushed, avulsed, or severed nerve. There is loss of function in the area served by the nerve. Unless the injury is identified, the nerve can be excised, and the severed nerve ends closely approximated. If left untreated, there is usually little or no return of function.

In addition to loss of function, painful neuromas can result from disorganized regeneration of axons at the fibrous, endoneural scar.3 Sydney Sunderland (1951) expand-

The next day the patient complained of numbness and weakness in her left upper extremity. A C5 brachial plexus neurapraxia was diagnosed, and her sensation and strength returned four days later with no specific treatment.

A 32-year-old man presented for laparoscopy-assisted sigmoid colectomy for treatment of recurrent diverticular disease. This was the patient’s first surgery, and he had no comorbidities. Shoulder braces were placed during positioning.

During the first 90 minutes of the surgery, the patient was in a 20-degree Trendelenburg position.

During the first 90 minutes, the blood pressure measurements (via arm cuff) varied between 100 mmHg and 140 mmHg systolic. Attempts at repositioning the cuff did not result in improved measurement, and the patient’s femoral pulses were strong and regular when palpated by the surgeon. The blood in the field was also noted to be bright red.

After 90 minutes, the shoulder braces were removed in an attempt to resolve the blood pressure measurement issues. Immediately after removal, the blood pressure measurements were strong and regular. However, after surgery the patient complained of bilateral shoulder and arm pain.

EMG studies showed severe upper trunk left brachial plexopathy and moderate upper trunk right brachial plexopathy. As of three-and-a-half years after surgery, the patient still reported shoulder and arm pain and had to change from full-time to part-time employment because of his iatrogenic disability.

As shown in these two cases, upper extremity nerve injuries can range from the benign to the disabling.

In the patient situations above, both injuries could have been prevented by clinical knowledge and careful attention to positioning.

MAY 2018 | OR TODAY |

33

IN THE OR

continuing education

ed on the three-part grading system. He defined neurotmesis to include grade 4, when the nerve fascicle is damaged but the myelin sheath is intact, and grade 5, when there has been significant perineural hemorrhage and scarring in all layers. Grades 4 and 5 are the most serious nerve fiber injuries and offer less chance of spontaneous or surgical repair.3

CE416

How to Earn Continuing Education Credit 1. Read the Continuing Education article.

2. Go online to ce.nurse.com to take the test for $12.

If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at https://www.nurse.com/ sign-up for $49.95 per year.

Deadline

Defending a legal case involving a nerve injury can be difficult. Patients may not remember exactly when their symptoms began and may assume that the symptoms are directly related to their surgery.

Moreover, many claims are paid even when the standard of care is met. The patient’s attorney often uses the theory of res ipsa loquitur, “the thing speaks for itself.” If a patient goes into surgery without an apparent nerve injury and returns from surgery with an injury or develops one later, the assumption often is that someone must have done something. Good documentation before, during, and after surgery will help avoid unnecessary legal action.

Proper positioning is essential for a safe and successful surgical procedure. The entire surgical team must work together to minimize chances of an intraoperative injury. 3

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.

EDITOR’S NOTE: Thomas Renter, MEd, BSN, RN, CRNA, and Don Beissel, MSNA, RN, CRNA, past authors of this educational activity, have not had an opportunity to influence this version.

Accredited

Staying Out of Court

Nancymarie Phillips, PhD, RN, RNFA, CNOR(E), is a retired professor of perioperative education for nurses and technologists at Lakeland Community College, Kirtland, Ohio. She is the author of several textbooks and articles, and has received the Lakeland Excellence in Teaching, Association of periOperative Registered Nurses’ Perioperative Clinical Educator Excellence, and Sigma Theta Tau Virginia Olsavsky Mentorship awards.

References 1. Kumar SD, Bourke G. Nerve compression syndromes at the elbow.

Orthopaedics Trauma. 2016;30(4):355-362.

2. Practice advisory for the prevention of perioperative peripheral neuropathies: an updated report by the American Society of Anesthesiologists Task Force on prevention of perioperative peripheral neuropathies.

Anesthesiol. 2011;114(4):741-754. doi: 10.1097/ALN.0b013e3181fcbff3 3. Phillips NM. Berry and Kohn’s Operating Room Technique. 13th ed. St. Louis, MO: Elsevier; 2016:479-498.

4. AORN. Guidelines for Perioperative Practice. Denver, CO: AORN Inc.; 2015:153-177,568-750.

5. Koehler SM, Meier KM, Lovy A, . Brachialis syndrome: a rare consequence of patient positioning causing postoperative median neuropathy.

J Shoulder Elbow Surg. 2016;25(5):797-801. doi: 10.1016/j.jse.2015.12.023.

6. Hussain MA, Aljabri B, Al-Omran M. Vascular thoracic outlet syndrome.

Semin Thoracic Cardiovasc Surg. 2016;28(1):151-157.

7. AORN. Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. 3rd ed. Denver, CO: AORN Inc.; 2011:61,96,125,178-184,454..

34 | OR TODAY | MAY 2018

In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider #50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider #CEP16588.

ONLINE

Questions

Nurse.com/CE You can take this test online or select from the list of courses available.

Prices subject to change.

Questions or for a complete listing of our courses Phone: 800-866-0919 Email: ce@nurse.com

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IN THE OR

continuing education

Clinical VignettE For CE416 George arrives in the preoperative holding area for his upcoming right inguinal hernia repair and is about to be seen by the perioperative team. George is 68 years old and weighs 176 pounds (80 kg).

He has several risk factors for surgery, including high blood pressure, osteoarthritis, and a history of smoking (half a pack per day for 50 years). His arms are contracted moderately, and he cannot straighten them fully. The surgeon requests that the patient be positioned supine with his arms on arm boards. The healthcare team discusses their concerns with the surgeon about positioning the patient in this manner.

1 I n the case of this patient, which factor is known to increase the risk of incurring an upper extremity nerve injury?

a. Smoking b. Age c. Weight d. High blood pressure

hich is recommended 2 W

when positioning George’s arms on arm boards?

hat should be performed 3 W

before George enters the OR?

a. The patient should be heavily sedated so he will not feel any pain while his arms are positioned. b. T he arm boards should be checked for proper functioning by sitting on them. c. T he patient’s arms should be put gently into the positions he will experience, checking for resistance or pain. d. No special preparation is needed.

a. The arms should be straightened so all parts will contact the arm board’s padding.

hich is TRUE regarding 4 W

b. U npadded arm boards will distribute the pressure more evenly.

a. The OR team’s responsibility ends when the patient is turned over to the recovery room.

c. The arms should be tucked at the sides, not placed on arm boards.

b. P ostoperative assessment may lead to early recognition of peripheral neuropathies.

d. The arms should be padded in a position of comfort for the patient.

c. A ny peripheral neuropathy is immediately evident.

postoperative care?

d. Once a neuropathy occurs, there is no specific treatment for it.

1. Answer: B, Men between 50 and 75 years are at increased risk for ulnar neuropathy. George’s weight is not at the extreme of body habitus that increases risk. Smoking and blood pressure are not specific risk factors for nerve injury. 2. Answer: D, The arms should be padded in a position of comfort for the patient. Straightening the arms and using unpadded arm boards are contraindicated.

There is no specific indication to tuck the arms in lieu of arm boards. 3. Answer: C, A patient who is awake can be assessed for tolerance of the planned position. Excessive sedation will not allow the patient to express discomfort with the position. Arm boards should be checked for proper functioning by gently leaning on them. Extra padding also should be made available in the OR. 4. Answer: B, Early identification can lead to early intervention in the case of a neuropathy. Not all neuropathies, however, manifest themselves immediately after surgery. When one is identified, the patient should be referred to neurology for further assessment and treatment.

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MAY 2018 | OR TODAY |

35

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CORPORATE profile

Key Surgical

CORPORATE PROFILE ey Surgical has been in the business of sterile processing and O.R. supplies for over 30 years. One of the things that keeps us on our toes and excited to come to work every day is that we know that the products we sell and the education we provide are helping improve our customers’ processes with the end goal of positive surgical outcomes, explains Corporate Marketing Director Alana Suomela.

K

“When someone plans to have surgery the first thing that comes to mind is never, ‘I wonder if the instruments being used on me were properly cleaned and sterilized.’ Most people don’t even think about cleaning of surgical instruments – they just trust that the instruments or supplies being used in surgery are sterile,” Suomela adds. “Unfortunately, we know that is not always the case and to that end we

38 | OR TODAY | MAY 2018

put ourselves in the shoes of the patient.

We think about our family members or loved ones being on the surgical table and that truly motivates and inspires us to do what we do. We talk about this often at Key Surgical and when we shift our thinking in this way, we’re no longer just a vendor selling a product. We don’t want our customers to cut corners when it comes to someone’s life on the line – so we don’t either.”

OR Today interviewed Suomela and Clinical Education Manager Lindsay Brown, CRCST, C.F.E.R., CCSVP, to find out more about Key Surgical.

Q

hat product or service are W you most excited about right now?

Brown: Education is a platform in which Key Surgical invests time and energy because we believe it inspires an important shift in engagement and dedication both with our customers as well as with our employees. When it comes to professionals in both the surgical and sterile processing industry, we have invested in the idea of knowledge-share in terms of industry standards, recommended practices, process improvements and much more. It’s widely recognized that positive patient outcomes are deeply influenced by a facility’s (hospital, surgical center, etc.) ability to understand the chain of infection and likewise the ways in

which to break that chain. We focus on supporting the vision and dedication to reducing infection by providing educational opportunities that cover industry topics ranging from manual cleaning of surgical instruments to effective communication between sterile processing and the operating room.

We currently have an online education program that is free and available on our website. We strive to create relatable and engaging material and that includes our education program as well. We’ve developed a series of online videos that are paired with interactive quizzes that challenge participants to think critically about daily tasks as well as over-arching process improvements. The material is both IAHCSMM and CBSPD certified, based on industry standards and guidelines, and technicians receive continuing education credits (CEUs) required for certification. In addition to the online

WWW.ORTODAY.COM

SPECIAL ADVERTISING SECTION

We are passionate about creating meaningful experiences for our customers that have a lasting impact.

– Lindsay Brown, CRCST, C.F.E.R., CCSVP

education program, our Key Surgical sales team members also provide in-services and bring the educational material to facilities in person. The pairing of educational opportunities with high-quality products for sterile processing and the O.R. from Key Surgical has really helped facilities across the country meet their daily challenges head-on.

As Clinical Education Manager for Key Surgical, I’ve spent many years working alongside health care professionals who are emboldened by the idea that a patient’s life depends on the work done every day in sterile processing and the O.R. It’s incredibly inspiring and we are dedicated to infusing that energy into all we do here at Key Surgical. Our goal is to compel our customers to act; to make changes in their department for the better and shift their mindset in a way that doesn’t leave room for interpretation of what is the “right thing to do.” If patient safety guides every decision in the department and the personnel responsible for performing tasks such as manual cleaning, protecting instruments, implementing new processes, etc. are given the tools they need to succeed … change happens for the better.

Education strengthens professional aptitude, which is crucial for health care professionals, and we are thrilled to be supporting them as they perfect the skills necessary for positive patient outcomes.

Q

ou mentioned being “inY spired” by your customers.

How does that drive your company’s evolution?

Brown: We are passionate about creating meaningful experiences for our customers that have a lasting impact and that will always be the basis of what we do at Key Surgical. With that said, the only thing constant WWW.ORTODAY.COM

MAY 2018 | OR TODAY |

39

CORPORATE profile

SPECIAL ADVERTISING SECTION

Key Surgical

is change and we will certainly evolve in terms of education (topics, design, availability) as well as the products we offer. We are already hard at work adding new products to our current line that will play an important role in our customers’ jobs, supported by a vibrant and approachable education program aimed toward success in the patient care setting. We view our customers as partners in our process as a business and we will continue to provide solutions that align with the ever-evolving needs of the industry.

Q

ell me about your employees.

T How do you promote that “partnership” sentiment within your company culture?

Brown: Part of our company’s mission statement is to hire and retain good people who understand that nothing happens until a customer decides to do business with us. Everyone at Key Surgical understands the impact our products and process have on patient safety in terms of positive surgical outcomes and reducing patient risk. We require all our sales team members to be IAHCSMM vendor certified (CCSVP) and all new hires are cross-trained in various departments to gain a full understanding of how essential each department is

40 | OR TODAY | MAY 2018

to the process. Each Key Surgical team member brings a wealth of knowledge and experience; their everyday contribution is “key” to how we operate and deliver on promises to our customers.

We focus on superior customer service and experience with each interaction – whether that be with a customer service team member, a sales team member, our Purchasing/AR department or visiting us in person at a national tradeshow event, we believe we are nothing without our customers and we promote that in our culture. An important group of employees who are woven into the fabric of who we are as a company come to us from Lifeworks, a Minnesota nonprofit organization whose mission is to serve our community and people with disabilities as we live and work together.

Our Lifeworks employees perform tasks in many different areas of our company and we are thankful for their dedication to upholding the mission of Key Surgical and producing the highest quality products and solutions for the customers we serve.

Q

our company is based in MinY nesota – how can customers around the country (or globally) interact with you in person?

Suomela: We proudly support indus-

try associations/organizations (such as IAHCSMM, AORN, ASCA, APIC, AAMI and AHRMM) all around the U.S. and internationally through either speaking at educational seminars or participating as an exhibiting vendor. Although our headquarters are in Minnesota, health care professionals around the country can interact with us in person at these events each year. We love exhibiting at these events because it gives the attendees a chance to check out our products in person, ask specific questions and receive a free bag of product samples they can take back to their facility to try out. Internationally, all our companies (Key Surgical, Interlock and Clinipak) have a combined presence at events such as the MEDICA TradeFair, World Sterilization Congress and Arab Health – which gives us the unique opportunity to meet with both customers and international distributors in person. Staying connected with our customers on all levels is vital to our mission and we will continue to seek opportunities to support them in their goals.

Visit keysurgical.com to participate in the online education program, learn about new products and find out when and how you can interact with them at an upcoming industry event!

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THE OR AND

SPD A VITAL COLLABORATION

By Don Sadler

It’s critical that OR personnel build strong relationships with other departments throughout the health care facility. But perhaps no partnership is as critical as the one between the OR and the sterile processing department (SPD).

SPD is responsible for a wide range of activities related to the cleaning and sterilizing of surgical instruments before use. These include decontaminating, inspecting, packaging, disinfecting, reprocessing and transporting all reusable surgical instrumentation.

According to David Taylor, MSN, RN, CNOR, the President of Resolute Advisory Group LLC, most SPDs are comprised of three different specialty areas: decontamination, assembly and sterilization, and storage and distribution.

A “SUBOPTIMAL” RELATIONSHIP

HANK BALCH, CO-FOUNDER & HOST, BEYOND CLEAN PODCAST

In his experiences working with numerous health care organizations, Taylor characterizes the relationships between the OR and SPD to generally be “suboptimal.”

“Both departments are faced with unique challenges in their day-to-day operations and neither truly understands the challenges each other faces on a daily basis,” Taylor says.

“The relationship between the OR and SPD is symbiotic – they are completely dependent on each other,” says Elbridge “Eb” Merritt, MSN, RN, CNOR, CHL, CRCST, CIS. “The best relationships are mutually respectful and collaborative.”

Hank Balch, the co-founder and host of the Beyond Clean podcast, believes that the quality of the relationship between the OR and SPD often correlates to the size of the hospital.

“Typically, there are better relationships between the two teams at smaller hospitals,” says Balch. “This is because there is a natural connectedness between them in both their proximity to each other and their mutually supportive roles.”

“As the size and complexity of the hospital grows and the physical distance between the two teams increases, the professional distance between them also tends to increase,” adds Balch.

But size and complexity are not always the determining factor in the quality of the relationship, he notes.

Ryan Rozinka, CRCST, CHL, technical service specialist with 3M Infection Prevention Division’s Sterilization Assurance Group, points out that the OR and SPD operate in silos in many health systems.

“Often, OR personnel do not have insight into what it takes to make the SPD function well,” he says.

“Likewise, the SPD does not understand the workflow and demands of the OR.” This disconnect can be compounded by a physical separation, says Rozinka.

“The SPD is typically in the basement of facilities while the OR suites are located on different floors, creating a disconnect and lack of understanding between the two departments,” he explains.

“To be frank, it can sometimes feel like a love-hate relationship between the OR and SPD,” Rozinka adds. “They must work together, but they don’t always understand each other.”

BEING PROACTIVE IS KEY RYAN ROZINKA, CRCST, CHL, TECHNICAL SERVICE SPECIALIST, 3M INFECTION PREVENTION DIVISION, STERILIZATION ASSURANCE GROUP

All of the experts emphasize the importance of the OR and SPD being proactive when it comes to improving relationships and collaboration with each other. According to Rozinka, this starts with understanding each other’s roles and how what each department does affects the other department.

“Doing so may heighten the importance of each department’s tasks in ensuring that patient safety comes first while helping lead to more efficient and thorough processes,” he says.

Balch concurs regarding the importance of a positive relationship between the two departments.

“Both teams have the same fundamental mission: ensuring safe patient care,” he says. “When the relationship sours, this negatively impacts everything – from clear communication, teamwork and efficiency to increasing the potential for processing errors and surgical delays.”

Merritt urges OR and SPD staff to “be positive, respectful and appreciative in your daily communication with each other.

Collaborate and support each other when improving processes and avoid ‘blame games’ at all costs – because once this begins, it can be a slippery slope.”

“Instead of pointing blame, OR and SPD

44 | OR TODAY | MAY 2018

teams can work together to implement checks and balances,” adds Rozinka. “This helps ensure that any issues along the way are resolved prior to the physician and patient entering the room.”

Taylor says it’s critical to proactively manage the day-to-day operations of SPD and the OR to make sure that both departments are working toward the same goals.

“This not only helps improve performance, but it also helps prevent patient injuries and the transmission of dangerous and sometimes deadly infections,” says Taylor. “And it keeps your organization from becoming the focus of the latest nationally televised or printed news story about a negative patient outcome.”

BRIDGING THE GAP The good news, says Rozinka, is that many health systems are working to bridge the gap and improve the connection between the OR and SPD. “More health systems are emphasizing collaboration between the OR and SPD,” he says. “For example, I’ve worked in SPDs where there’s an afternoon huddle to bring members from all areas together to discuss what went well and what didn’t that day.”

“These conversations can serve as a bridge to the next day by identifying any potential issues with turnover time and then adjusting the schedule to make sure that SPD has enough time to get the instruments prepared,” Rozinka adds.“To get a better understanding of the circumstances behind the scenes, it’s important to include staff from both departments in your morning awnd change-of-shift huddles,” Taylor adds.

“By including all staff, you’re able to break down barriers and facilitate better communication.”

‘WALK A MILE IN MY SHOES’ Taylor is a big proponent of rotating hospital employees through various departments to give them a better view of the big picture when it comes to successful surgical procedures.

“I call it ‘walk a mile in my shoes,’ ” he says. “Rotating staff through different

departments for up to two weeks at a time gives them a glimpse of what happens behind the scenes and the hard work accomplished by their peers to make surgery happen.”

Rozinka agrees.

“Requiring OR staff to spend time in the SPD during orientation can help them better understand the steps and time required to reprocess instruments, the importance of point-of-use cleaning, and how to prep case carts,” he says.

“Likewise, it’s important for SPD staff to observe the OR to get a better understanding of their needs,” Rozinka adds.

“The more each department understands each other’s roles and how their roles affect one another, the easier it is to close the gap and improve collaboration.”

Taylor recommends that SPD staff spend time directly observing surgical procedures.

“So when a surgeon is upset because the instrumentation doesn’t work as intended, they get to experience the stress this causes in the OR first-hand,” he says.Conversely, the actions of OR staff can have a big impact on SPD’s ability to process instruments effectively, Taylor adds.

“If the OR staff does not begin the cleaning process during the procedure by applying the appropriate enzymatic solutions prior to the instruments returning to SPD, then it takes longer for SPD to properly clean the instruments and return them for use,” he says.

AVOIDING COSTLY MISTAKES Both the OR and SPD are fast-paced, high-stress environments where mistakes can cost much more than just dollars and cents. So it’s critical that staff in each department learn to work closely together and collaborate effectively with each other.

“These two areas can get caught up in the busy pace and stress and lose track of how dependent they are on each another,” says Merritt. “That’s why teamwork, collaboration and mutual respect between the departments is so important – and why all employees should strive so hard to achieve this.”

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SPOTLIGHT ON:

a d n i L

r e d o Y eadership and education are abstract concepts that are increasingly intertwined in conversations about nursing professional development, but you’d be hard-pressed to find someone who embodies them as inclusively as Linda H. Yoder.

Her credentials are impressive enough – PhD, MBA, RN, AOCN, FAAN, and Col. U.S. Army (Ret.) – in the practitioner space, but for the past several years, Yoder has pressed into academia and advocacy as the Luci Baines Johnson Fellow in Nursing at the University of Texas at Austin School of Nursing and president of the Academy of Medical-

L

46 | OR TODAY | MAY 2018

Surgical Nurses (AMSN).

From an early age, the oldest of three children “was always the one in the family who sort of took care of everything,” Yoder said. “I was always the responsible one; I was always the one who was fixing the boo-boos or fixing the upset.”

Nursing might not have become a career choice had Yoder’s father not passed away unexpectedly during her teenage years. Despite high marks at school, she worried that she’d never be able to afford to attend college. But thanks to the intercession of a high-school guidance counselor, Yoder was encouraged to apply for a military scholarship, and won a seat in the last nursing class at the Walter Reed Army Institute of Nursing. She marks it as the beginning of a transformative career experience, as she began working

LOS

ATT

M BY

UFA SKO

as a nurse and a military officer.

“I had a job right away because I owed the army six years payback for the four years of college,” Yoder said. “My job was a little bit harder than the average nursing job. In addition to being a nurse at the bedside, I had to go out in the field and work in very austere environments.”

Over the course of 28 years with the U.S. Army, Yoder rose to the rank of colonel in an ascension that paralleled her academic achievements. Even early in her career, military service brought with it the expectations of leadership that Yoder said carried through into her civilian life. She pursued a master’s degree in nursing and later realized that “nurses were not getting the resources they needed because they couldn’t speak the business language.” From there, Yoder decided to obtain a second master’s degree in business.

“That, I feel, helped me later, in other senior administrative roles, to

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compete with other health care professionals for the resources that nurses needed,” she said. “I moved up with my military education as well, (U.S. Army) Command And General Staff College, and later, when I was a colonel, I went to the (U.S.) Army War College, and got a master’s in strategic studies.”

Her civilian and military education shaped her growth and development as a leader as well as being someone who believes that nurses should be leaders. Being surrounded by “people who demonstrated leadership on a daily basis” inspired Yoder to model the kind of attitude toward leadership that she wanted the nurses working with her to exude.

“I’m a firm believer that nursing is not just a job,” Yoder said. “People that want to be nurses need to be committed to the profession, they need to be committed to safe and quality patient care, and they need to have compassion for the patients that we take care of.”

“That is meaningful not just to nurses who work at the bedside and take care of patients; it also applies when you’re in an administrative role,” she said. “Those nurses need nurse executives to be on their side when they’re caring for very complex patients.”

Yoder said she works to help nurses avoid minimizing their role in the larger continuum of care at a hospital or health center. She advises them to apply their education to self-advocacy, including understanding that they’re capable of performing in leadership roles. Just like in the military, Yoder said she urges her staff to step up; to volunteer to be on a committee or on a task force; to develop additional cooperative skills from working with different teams.

“I want them to broaden their horizons and take on challenges,” she said. “You may not be able to do that in the first year or two that you’re WWW.ORTODAY.COM

a new nurse, but after that, I want to see people stepping up, taking on some of these roles.”

“At the same time, I want them, when they’re in these roles, to not just show up at the meeting and sit there,” Yoder said. “I want them to speak up and make their voices heard; to appropriately state their opinions. It doesn’t help if you show up and there’s no voice.”

Yoder applied that same approach to her decades of volunteerism with the Academy of Medical-Surgical Nurses. Her term as president is set to expire in the fall and as she prepares to hand over the reins of the organization to the next leader, she is working on how to best communicate the business case for nursing resources to AMSN members.

“Nurses generally don’t know how to acquire and use data to their benefit before they get a master’s degree,” Yoder said. “There’s some things that bedside nurses can do by collecting simple data. In the business world, things revolve around data. If you want to make the case well, you have to have the data to support your argument.”

Hand in hand with that strategy, Yoder said she urges nurses to make their voices heard as long as their complaints are accompanied by constructive suggestions. She views the approach as part and parcel of leadership skills that successful nurses acquire along the path of selfadvocacy and individual growth.

“Clinical nurses may not do those things as well as we need to be doing them within health care settings, not just hospitals,” she said. “The AMSN Board has been working on having a greater national presence, more collaboration with other nursing organizations. I want to see that reciprocity as far as educational opportunity for our members.”

++

Even early in her career, military service brought with it the expectations of leadership that Yoder said carried through into her civilian life.

MAY 2018 | OR TODAY |

47

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49

OUT OF THE OR fitness

Fitness Trackers Often Inaccurate

when it comes to monitoring sleep stages EAR MAYO CLINIC: I wear a fitness device that tracks my sleep. It shows that most of my sleep is light sleep and that I rarely am in deep sleep. Is this kind of sleep tracker reliable? If so, is there a way I can get better sleep? I sleep about six or seven hours each night.

D

ANSWER: When it comes to identifying the difference between light sleep and deep sleep, research has shown that fitness trackers are not accurate. Rather than relying on your device to measure how well you sleep, consider basing your assessment of sleep quality on how you feel when you wake up. If you don’t feel well-rested, and it’s affecting your daily life, that might prompt a change in your habits or possibly a sleep evaluation.

Wearable fitness trackers and apps that claim to measure sleep have become quite popular. Typically, they display information about sleep and wake time. Some offer assessment of light sleep versus deep sleep, as well as how often you wake up during the night and how long you stay awake. The manufacturers don’t share details about the technology these devices use to gather the information, but it appears that most rely on motion detection.

To evaluate the usefulness of wearable trackers and apps, more than 20 research studies have examined the accuracy and validity of the sleep information they generate. The results show that, when compared to polysomnography – considered by sleep medicine specialists to be the gold standard of sleep tests – the devices

50 | OR TODAY | MAY 2018

are largely inaccu“A better way to tell if you’re getting rate. Their accuracy particularly deteriorates for people the sleep you need is to consider who wake up often during the night. how you feel throughout the day.”

In addition to being unreliable in sleep-wake schedule, and make sleep distinguishing between different sleep a priority. But don’t spend more than stages, the sleep trackers and apps are about eight hours in bed per day. inexact in their ability to measure the Avoid caffeine after noon, and limit it time it takes to fall asleep, overall sleep to one or two servings. Exercise during efficiency and total sleep time. The the day, but try to do so at least six general problem is that, although the hours before you go to bed. devices are fair to good at detecting Take time to wind down before when you’re asleep, they are poor at bed, and establish a daily bedtime roudetermining when you are awake during tine. Use the bedroom only for sleep the night. and sex. Avoid excess alcohol use and A better way to tell if you’re getheavy meals before bedtime. Remove ting the sleep you need is to consider electronics from your bedroom, and how you feel throughout the day. You avoid looking at the clock. When you mention that you usually get six or go to bed, wear comfortable clothing, seven hours of sleep. Based on existing and keep your surroundings dark, cool sleep research, the American Academy and quiet. If you can’t fall asleep, get of Sleep Medicine recommends healthy out of bed and do a boring activity adults consistently get at least seven until you become drowsy. hours of sleep a night. If you wake in If you feel persistently sleepy, dethe morning feeling well-rested and able spite good sleep habits, or if you have to function throughout the day, there’s other symptoms of sleep problems, probably no need to be concerned. make an appointment to see your If, however, you have any of these health care provider. He or she can symptoms, consider seeking medical evaluate your situation and help you evaluation: significant difficulty falling decide if a consultation with a sleep asleep or staying asleep; frequent loud specialist may be useful. snoring; waking up with a gasping or choking sensation; breathing pauses in Mayo Clinic Q & A is an educational resleep; frequently waking up; waking in source and doesn’t replace regular medical the morning after a full night’s sleep not care. Email a question to MayoClinicQ&A@ feeling refreshed or with a headache; or mayo.edu. For information, visit www. often feeling sleepy during the day. mayoclinic.org.

Some changes can improve your sleep. Try to maintain a consistent WWW.ORTODAY.COM

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51

OUT OF THE OR health

Anxious? WHO ISN’T?

Time to Move with Mindfulness

BY MARILYNN PRESTON “

dam” is a guy I’ve created to illustrate one big and fascinating idea from a new book by British psychotherapist William Pullen: Movement is medicine.

A

Yes! Forget the word “exercise” for now. Just moving our bodies – walking, dancing, jogging, preferably in nature – can help free us from stress, emotional pain and whatever else we’re dealing with that makes our bodies feel stuck, unsettled and depressed.

This therapeutic connection between the mind and body isn’t a theory; it’s a fact of life. Your body is self-healing and wondrous, and when you move it you automatically get the health benefits that come from the blood and lymph flowing, the molecules of emotion circulating, the tissues nourished, the joints juiced.

And when you add mindfulness to movement, therapist Pullen explains, you’re on a self-directed path to enhanced well-being, physical and mental.

Bravo!

So back to Adam: In our hypothetical scenario, Adam is stressed to the point of depression. He’s not sleeping.

He can’t focus at work. And he’s starting a relationship with Johnnie Walker in startling and destructive ways.

Why? Because his wife wants a divorce. He’s shocked but also a little relieved. Maybe he’d be happier without her. What should he do?

“DRT (Dynamic Running Therapy) is a powerful and engaging step-bystep therapeutic method for confronting difficult feelings and circumstances in your life through movement,” writes

52 | OR TODAY | MAY 2018

Pullen, author of “Running With Mindfulness,” in which he enthusiastically gives detailed instructions.

Adam – a slow runner, but that doesn’t matter – could use DRT to work through challenging issues around divorce. But Pullen assures us this revelatory combo of movement, mindfulness and provocative questions is also good for dealing with anger, letting go of fear, overcoming the terrors of perfectionism and more.

The acronym DRT stands for Dynamic Running Therapy, but it’s certainly not limited to running or runners. Anyone can do it, at any level of fitness, alone or with a trusted listening partner, as long as you’re willing to commit to the process and follow a number of steps.

Adam manages to do most all of them – from head-to-toe body scans before he runs to journaling for a few minutes right after. At the end of his time, using Pullen’s techniques, he moves on to a much happier and healthier relationship with wife No. 2.

Such a satisfying ending. Such an enlightening book. Here are a few more of Pullen’s steps “to get moving, get mindful, and lift yourself out of low moods.”

LISTEN TO YOUR BODY DRT isn’t designed to involve challenging exercise. If you can barely walk a block, you can still do it. Think of it as a tool for increasing your selfawareness and your body awareness, a method for “noticing the tone of your inner dialogue and meeting whatever you find there with acceptance and patience.”

MAKE ROOM FOR FEELINGS When you move with intention and focus on a particular question – e.g., “Where does the anxiety about divorce live in my body?” – you will reconnect with feelings you may have hidden deep down. “Emotion in motion can be very powerful,” therapist Pullen writes, so be prepared to welcome those feelings, without judgment or shame.

DON’T STRIVE TOO HARD Mindful movement isn’t like conventional exercise. Striving too hard can create more stress and anxiety. “The key is finding your own pace, finding your footing and finding yourself. It will happen on its own if you stay present. ... The pain you feel when you are depressed provides an ongoing opportunity to improve your mindful practice,” Pullen writes, cheerfully.

“Each time you feel the bark of the black dog it is a chance to come back once more to the body, to sensation, and to recognize that thoughts come and go, feelings come and go. ...

Acknowledge the thought or feeling as just that, and let it pass on by.”

If you get a busy signal when you think about your “inner dialogue,” don’t stress. Pullen’s book gives you lots of questions and prompts to guide you. It’s a process, he reminds us, and if you’re patient and forgiving, you’ll discover gold.

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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MAY 2018 | OR TODAY |

53

OUT OF THE OR nutrition

Is Poor Nutrition Keeping You Up at Night?

By Joy Stephenson-Laws ost of us know what sleep deprivation feels like, and it is not pleasant. If we do not get enough healthy sleep (some children need 10 hours nightly, while most adults need at least seven), we may be left feeling irritable and disoriented. It can also be dangerous to be sleep deprived.

M

According to the AAA Foundation for Traffic Safety, drivers who usually sleep for less than five hours daily, have slept for less than seven hours in the past 24 hours or have slept for one or more hours less than their usual amount of sleep in the past 24 hours have significantly elevated crash rates.

“The estimated rate ratio for crash involvement associated with driving after only 4-5 hours of sleep compared with 7 hours or more is similar to the U.S. government’s estimates of the risk associated with driving with a blood alcohol concentration equal to or slightly above the legal limit for alcohol in the U.S.,” reports AAA. You read that right.

Driving sleepy may share similar risks to drunk driving.

And while some of us do not get enough sleep because we go to bed too late or work through the night, there are also millions of Americans

54 | OR TODAY | MAY 2018

who have trouble sleeping due to disorders such as sleep apnea, insomnia and restless leg syndrome.

The Centers for Disease Control and Prevention (CDC) reports, “[p]ersons experiencing sleep insufficiency are also more likely to suffer from chronic diseases such as hypertension, diabetes, depression, and obesity, as well as from cancer, increased mortality, and reduced quality of life and productivity.”

The obvious solution is to get more sleep, but, of course, that is much easier said than done.

You could try to get more sleep perhaps by scheduling an evening cutoff time for phones and other technology, meditating or taking a hot bath.

But it’s my opinion that nutrition plays a huge role in ensuring that you get adequate sleep.

Make sure you get enough iron in your diet According to the National Institutes of Health (NIH), deficiencies in the mineral iron may be related to restless leg syndrome, a cramping in the legs that causes an irresistible urge to move them. Iron-rich foods include red meat, pork, poultry, seafoods, beans, spinach (and other

leafy greens), peas, cherimoyas and iron-fortified cereals. The NIH also says B vitamins may help with nocturnal leg cramps.

Make sure you get enough vitamin D in your diet The NIH found that people with lower vitamin D serum levels had more sleep disturbances. They also found evidence of this when examining mice. “In animal studies, vitamin D receptors have been found in specific regions of the central nervous system, some of which regulate sleep … ” reports NIH.

Make sure you get enough magnesium in your diet The NIH conducted a study with elderly people and found that magnesium supplementation helped with sleep onset and insomnia. This makes sense considering magnesium is needed by more than 300 human body enzymes to facilitate biochemical reactions. Foods containing magnesium include spinach, pumpkin seeds, yogurt, kefir, almonds, black beans, avocado, figs, dark chocolate and bananas.

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Make sure you get enough calcium in your diet As a child, did your parents ever try to get you to sleep by giving you a glass of warm milk? If they did, they most likely did this to calm you down.

But several studies show calcium is directly related to our sleep cycles.

Calcium causes the release of melatonin, which explains why this mineral is not only important for strong bones and teeth but also for preventing insomnia and helping people get healthy sleep

Eat more kiwis A study published by the NIH revealed that eating kiwis before bedtime may help people who have trouble sleeping or have actual sleep disorders.

The study examined males and females between the ages of 20 to 55.

The subjects consumed two kiwis one hour before bedtime for four weeks. The results revealed the subjects fell asleep quicker, had longer sleep durations and had better quality sleep. “Numerous studies have revealed that kiwifruit contains many medicinally useful compounds, among which antioxidants and serotonin may be beneficial in the treatment of the sleep disorders,” reports the NIH. WWW.ORTODAY.COM

Eat more cherries Cherries, especially tart cherries, contain melatonin. Melatonin is a “sleep hormone” your body naturally produces.

It is inactive during the day and starts to kick in after the sun goes down, around 9 p.m. according to the National Sleep Foundation. If you have trouble sleeping and take melatonin supplements, taking a shot of natural cherry juice at night may be a good alternative. Melatonin may help reset your sleep and wake cycles, which can also aid in alleviating jet lag.

Maintain a healthy weight Obesity and sleep problems go handin-hand. According to the National Sleep Foundation, “[a]n estimated 18 million Americans have sleep apnea, a sleep-related breathing disorder that leads individuals to repeatedly stop breathing during sleep.

Not only does sleep apnea seriously affect one’s quality of sleep, but it can also lead to health risks such as stroke, heart attack, congestive heart

failure and excessive daytime sleepiness. Sleep apnea is often associated with people who are overweight – weight gain leads to compromised respiratory function when an individual’s trunk and neck area increase from weight gain.”

Along with exercising and making sure to maintain a healthy diet, there are certain minerals you may want to make sure you are getting adequate amounts of. Magnesium, phosphorus, iron and zinc are all associated with weight management.

As humans, our bodies can do amazing things. Sometimes we push our limits and overexert ourselves.

We have to accept that sleep is a vital piece to the puzzle of being proactive about our health. And just like with most things related to our health, eating healthy foods and getting adequate vitamins and minerals are intertwined.

Healthy food is medicine!

Enjoy your healthy life!

Joy Stephenson-Laws is the founder of Proactive Health Labs (www.phlabs.org), a national non-profit health information company that provides education and tools needed to achieve optimal health. Her most recent book is “Minerals – The Forgotten Nutrient: Your Secret Weapon for Getting and Staying Healthy.” It is available through Amazon, iTunes and bookstores.

MAY 2018 | OR TODAY |

55

OUT OF THE OR

Recipe

recipe

the

56 | OR TODAY | MAY 2018

INGREDIENTS: • 1 tablespoon unsalted butter • 1/2 large onion, diced • 1 teaspoon kosher salt • 3 medium carrots, peeled, halved lengthwise and sliced crosswise • 3 cloves garlic, minced • 2 medium celery stalks, sliced • 1 medium red bell pepper, seeded and diced • 2 boneless, skinless chicken breasts (about 1 pound total) • 1 bay leaf • 1 Parmesan cheese rind • 1 quart low-sodium chicken broth • 1 pound refrigerated cheese tortellini • 1 cup half-and-half • 2 cups fresh spinach (about 2 ounces), coarsely chopped • 1 tablespoon chopped fresh parsley leaves • 1 teaspoon chopped fresh oregano leaves • 1/4 teaspoon freshly grated nutmeg • 1/4 teaspoon freshly ground black pepper • Grated Parmesan cheese, for serving

Patty Catalano is a contributor to TheKitchn.com, a nationally known blog for people who love food and home cooking.

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OUT OF THE OR recipe

This Creamy Chicken Soup Has a Few Shortcuts Up Its Sleeve As winter wanes into spring, it is perfectly normal to crave both creamy comfort food and the bright spark of fresh veggies. This soup has it all: tender chicken, chunky carrots, wisps of wilted spinach, bite-sized pillows of pasta and cheese, all with a silky broth to tie it together.

The Dutch oven is the workhorse of my kitchen. For most of the year it camps out on the back of my stove, awaiting the splash of oil and sizzle of onion. Some days this humble pot is filled with bread for baking, other days it’s slowly simmering stock. On Saturdays I use it to put grocery store staples to work in this simple, satisfying soup. Red pepper and garlic join the classic trio of onion, carrot and celery for a quick sauté.

Dig through the freezer to retrieve a rind of Parmesan saved for just such an occasion, or if you have not had the forethought simply purchase a pack of Parmesan rinds from the cheese counter of your grocery store. A few breasts of chicken simmer until tender enough to pull (although I’ve skipped this step and substituted the shredded meat of a rotisserie chicken in a pinch). Stir in two handfuls of greens – one spinach and the other mixed herbs – and a splash of half-and-half, and the soup is ready to serve.

Pull out your biggest spoon for a taste of velvety broth, cheesy tortellini, juicy chicken and tender vegetables in every bite. Even if your weekend plans leave you just an hour to spare before supper, this is the Saturday soup to warm you through bone-chilling winter days and mild spring nights.

Creamy Chicken Tortellini Soup Serves 6 1.

Melt the butter in a 4-quart Dutch oven or saucepan over medium-high heat.

Add the onion and salt, and sauté until softened and beginning to brown, 3 to 4 minutes. Add the carrots, garlic, celery and bell pepper, and cook until the carrots brighten in color, 3 to 4 minutes.

2. Add the chicken breasts, arranging them in a single layer. Add the bay leaf and Parmesan rind, and then pour in the chicken broth. Cover and bring to a boil over medium-high heat. Uncover, reduce the heat to low, and simmer until the chicken is cooked through and an instant-read thermometer inserted into the thickest part registers 165 F, 8 to 12 minutes.Remove and discard the bay leaf and Parmesan rind. Use tongs to transfer the chicken to a clean cutting board, and let cool slightly.

3. Meanwhile, add the tortellini to the soup and cook for 7 minutes, stirring occasionally.

4. Once cool enough to handle, shred the chicken with 2 forks or cut it into bitesized pieces, then add it back into the soup. Stir in the half-and-half, spinach, parsley, oregano, nutmeg and black pepper. Cook until the spinach wilts, 1 to 2 minutes. Ladle into bowls and serve with grated Parmesan cheese.

Recipe notes: Refrigerate leftovers in an airtight container for up to four days.

Tortellini will soak up the liquid upon storage, so you will have to add extra broth and half-and-half when reheating.

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MAY 2018 | OR TODAY |

57

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OUT OF THE OR pinboard

OR TODAY

• CONTEST • M AY

TAKE YOUR BEST Email us a photo of yourself or a colleague reading a copy of OR Today and you could win a $50 Subway gift card!

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

Win Lu n

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The Winner Gets a $50 Subway Gift Card!

Top tips for planning an epic family vacation Are you dreaming about an incredible family escape your loved ones will always remember? Fortunately, with a few tips from those in the know, creating an unforgettable getaway can be as magical as taking one.

Tip #1: Get the inside scoop No idea where to begin? Talk with a trustworthy resource or fellow parent who has “been there.” The honest and relatable vacation tips you’ll receive are invaluable and can ease the planning process. For example, individuals thinking about planning a Disney vacation should visit www. disneyparksmomspanel.com, an online resource providing authentic answers to guests seeking advice from in-the-know panelists with years of vast experience.

Tip #2: Find an all-appealing destination You probably have a few ideas of where to go, but brainstorming destinations with your travel crew

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can provide helpful feedback and insight into everyone’s interests.

Maybe your best friends are making brunch a priority for your girlfriends’ getaway. Or Grandma has a few “memory making” ideas for her vacation with the grandkids. Your fickle pre-teen even has a dream destination you might not know of, and your kindergartner is sure to throw a few ideas into the ring.

After you make a list of everyone’s thoughts, do some research online. Poke around travel websites and talk with other parents. With a little digging, you can find experiences that appeal as much to your toddler as your teenager and even your best friend.

Tip #3: Be proactive about special requirements Keep special needs top of mind when booking accommodations.

For example, all U.S. hotels are required to offer wheelchair-accessible rooms, but international hotels

follow different guidelines, so be sure to ask. Additionally, if you have a sensitive child who prefers a calmer environment, book a hotel room away from the pool or other entertainment spaces.

Another common concern for families is food allergies. To ease worries, plan ahead. Experienced jetsetters suggest asking restaurants for their ingredients charts and nutrition information or requesting to speak directly to the chef. You can even call airlines and hotels early to ask about allergy policies.

– Brandpoint

MAY 2018 | OR TODAY |

59

OUT OF THE OR scrapbook

AORN SCRAPBOOK

5. An impressive booth at AORN from Tidi.

6. Attendees gathered at a VIP event hosted by OR Today and BD. 7. imp demonstrates its products to eager attendees.

8. Disinfection was the focus at the Tru-D Smart UVC display.

9. MD Publishing President John Krieg is pleased to find a fellow New Orleans enthusiast.

The AORN Global Surgical Conference and Expo took place in New Orleans, March 24-28. Attendees benefited from education and a lively exhibit hall. OR Today was on site to meet readers from around the world, share an invitation to join us at the OR Today Live Surgical Conference and provide busy professionals a chance to unwind at our VIP event.

1. The exhibit hall included a wide variety of vendors that service the OR, including Diversey who showcased disinfection products.

2. Key Surgical draws a crowd on opening day of the expo.

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3. With a stack of different OR mat solutions to showcase, Gel Pro stood comfortably in their booth.

4. The OR Today booth was a buzz with news of the OR Today Live conference heading to Nashville in August.

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6

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10. BD provided attendees a relaxing venue to network at the VIP event on Sunday evening.

11. Attendees gathered at a VIP event hosted by OR Today and BD. 12. Stepping away from the OR Today booth, Jena Mattison snuggles Pink Pad XL on the showroom floor.

13. OR Today team members Kristin Leavoy, Lisa Gosser, John Krieg and Lisa Cover are all smiles after a successful AORN 2018.

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MAY 2018 | OR TODAY |

61

INDEX

advertisers

Alphabetical

AIV Inc.………………………………………………………… 53 Alco Sales Service, Co.……………………………… 49 Avante Health Solutions………………………………21 BD………………………………………………………………… 58 C Change Surgical……………………………………… 13 Capital Medical Resources……………………………17 CSZ, A Gentherm Company……………………… 45 Cygnus Medical……………………………………………… 9 D. A. Surgical……………………………………………… 63 Doctors Depot…………………………………………… 26

Fobi Medical………………………………………………… 51 GelPro…………………………………………………………… 15 Healthmark Industries Company, Inc.…… 4,6 Innovative Medical Products…………………… 64 Jet Medical Electronics Inc………………………… 11 Key Surgical…………………………………………… 38-41 MD Technologies inc.………………………………… 22 Medi-Kid Co.………………………………………………… 58 MedWrench………………………………………………… 36 Pacific Medical…………………………………………… 49

Paragon Services………………………………………… 37 Parkdale Center for Professionals…………… 48 Ruhof Corporation…………………………………… 2, 3 SIPS Consults……………………………………………… 19 Soma Technology……………………………………… 51 TBJ Incorporated…………………………………………… 5 Tetra……………………………………………………………… 48 USOC Medical……………………………………………… 27

MEDICAL GAS

REPROCESSING STATIONS

categorical ANESTHESIA

Doctors Depot…………………………………………… 26 Paragon Services………………………………………… 37 Soma……………………………………………………………… 51

C-ARM

Soma……………………………………………………………… 51

CARDIAC PRODUCTS

Fobi……………………………………………………………… 51

MONITORS

Doctors Depot……………………………………………

Pacific Medical……………………………………………

Soma………………………………………………………………

USOC Medical………………………………………………

C Change Surgical……………………………………… 13 Jet Medical Electronics Inc………………………… 11

ONCOLOGY SERVICES

CARTS/CABINETS

ONLINE RESOURCE

Alco Sales Service, Co.……………………………… 49 Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.…… 4,6 TBJ Incorporated…………………………………………… 5

CS/SPD

MD Technologies inc.………………………………… 22

DISINFECTANTS

Cygnus Medical……………………………………………… 9 Ruhof Corporation…………………………………… 2, 3

DISPOSABLES

Alco Sales Service, Co.……………………………… 49 BD………………………………………………………………… 58

ENDOSCOPY

Capital Medical Resources……………………………17 Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.…… 4,6 MD Technologies inc.………………………………… 22 Ruhof Corporation…………………………………… 2, 3

FALL PREVENTION

Alco Sales Service, Co.……………………………… 49

GENERAL

Capital Medical Resources……………………………17

HOSPITAL BEDS/PARTS

Alco Sales Service, Co.……………………………… 49

INFECTION CONTROL

Alco Sales Service, Co.……………………………… 49 BD………………………………………………………………… 58 Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.…… 4,6 Ruhof Corporation…………………………………… 2, 3 SIPS Consults……………………………………………… 19 TBJ Incorporated…………………………………………… 5

INSTRUMENT STORAGE/TRANSPORT

Cygnus Medical……………………………………………… 9 Key Surgical…………………………………………… 38-41

INVENTORY CONTROL

Key Surgical…………………………………………… 38-41

62 | OR TODAY | MAY 2018

26 49 51 27

Avante Health Solutions………………………………21 MedWrench………………………………………………… 36

OR TABLES/BOOMS/ACCESSORIES

D. A. Surgical……………………………………………… 63 Innovative Medical Products…………………… 64 Soma……………………………………………………………… 51

OTHER

TBJ Incorporated…………………………………………… 5

RESPIRATORY

Soma……………………………………………………………… 51

SAFETY

GelPro…………………………………………………………… 15 Healthmark Industries Company, Inc.…… 4,6 Key Surgical…………………………………………… 38-41

SINKS

TBJ Incorporated…………………………………………… 5

STERILIZATION

Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.…… 4,6 TBJ Incorporated…………………………………………… 5

SURGICAL

Medi-Kid Co.………………………………………………… 58

Avante Health Solutions………………………………21 BD………………………………………………………………… 58 Fobi……………………………………………………………… 51 MD Technologies inc.………………………………… 22 SIPS Consults……………………………………………… 19 Soma……………………………………………………………… 51

OTHER: FLOOR MATS

SURGICAL INSTRUMENT/ACCESSORIES

AIV Inc.………………………………………………………… 53 Parkdale Center for Professionals…………… 48

OTHER: CRANIOFACIAL RECOVERY PRODUCTS

GelPro…………………………………………………………… 15

OTHER: PEDIATRICS

Medi-Kid Co.………………………………………………… 58

PATIENT MONITORING

AIV Inc.………………………………………………………… 53 Avante Health Solutions………………………………21 Jet Medical Electronics Inc………………………… 11 Pacific Medical…………………………………………… 49 USOC Medical……………………………………………… 27

PATIENT WARMING

CSZ, A Gentherm Company……………………… 45

POSITIONING PRODUCTS

Cygnus Medical……………………………………………… 9 D. A. Surgical……………………………………………… 63 Innovative Medical Products…………………… 64 Medi-Kid Co.………………………………………………… 58

RENTAL/LEASING

Avante Health Solutions………………………………21

REPAIR SERVICES

Capital Medical Resources……………………………17 Cygnus Medical……………………………………………… 9 Doctors Depot…………………………………………… 26 Jet Medical Electronics Inc………………………… 11 Pacific Medical…………………………………………… 49 Soma……………………………………………………………… 51

C Change Surgical……………………………………… 13 Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.…… 4,6 Key Surgical…………………………………………… 38-41

SURGICAL LAMPS

Fobi……………………………………………………………… 51

SURGICAL TABLE

Fobi……………………………………………………………… 51

TELEMETRY

AIV Inc.………………………………………………………… 53 Pacific Medical…………………………………………… 49 USOC Medical……………………………………………… 27

TEMPERATURE MANAGEMENT

C Change Surgical……………………………………… 13 CSZ, A Gentherm Company……………………… 45

WARMERS

CSZ, A Gentherm Company……………………… 45

WASTE MANAGEMENT

MD Technologies inc.………………………………… 22 TBJ Incorporated…………………………………………… 5

WOUND MANAGEMENT

Tetra……………………………………………………………… 48

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