OR Today - September 2018 by MD Publishing

PRODUCT FOCUS PATIENT SAFETY

CE ARTICLE MALIGNANT HYPERTHERMIA

COMPANY SHOWCASE

SPOTLIGHT ON SARAH WOLF, BSN

SEPTEMBER 2018

www.ortoday.com

PROVEN PRACTICES PREVENT INFECTIONS

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OR TODAY | September 2018

contents features

PROVEN PRACTICES PREVENT INFECTIONS

36 PROVEN PRACTICES TO PREVENT INFECTIONS Despite technological advances and a growing awareness of the problem, infections remain a serious issue in many hospital operating rooms today. Infections can lead to a wide range of problems including delayed recoveries, extended hospital stays, readmissions, additional surgeries, increased costs, reduced or denied reimbursements, government penalties, lawsuits and even patient deaths.

Patient safety is vital and OR Today reached out to companies to find out what products they offer in this growing market.

The goal of this continuing education program is to provide OR nurses, physicians, and surgical technologists with information about malignant hyperthermia, including perioperative signs and management of the

The oneSOURCE Biomedical Document Database is growing constantly as it obtains new and updated material on behalf of its customers.

PRODUCT FOCUS

CE ARTICLE

COMPANY SHOWCASE

patient.

OR Today (Vol. 18, Issue #09) September 2018 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 30269-1530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530. For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. ÂŠ 2018

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SEPTEMBER 2018 | OR TODAY |

contents features

PUBLISHER John M. Krieg

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VICE PRESIDENT Kristin Leavoy

OR TODAY CONTEST

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win lunch for your department!

EDITOR John Wallace

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ART DEPARTMENT Jonathan Riley Karlee Gower Kathryn Keur

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DIGITAL SERVICES

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SPOTLIGHT ON

RECIPE OF THE MONTH

Travis Saylor Cindy Galindo Kennedy Krieg

CIRCULATION Lisa Cover Melissa Brand

WEBINARS

INDUSTRY INSIGHTS

Linda Hasluem webinar@mdpublishing.com

10 News & Notes 16 Company Showcase: oneSOURCE document site 18 Webinar Recap

IN THE OR

21 Market Analysis 22 Product Focus 26 CE Article

OUT OF THE OR 44 Fitness 46 Health 51 Nutrition 52 Recipe 56 Pinboard

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INDUSTRY INSIGHTS

news & notes

Mölnlycke Acquires German Wound Care Company

Encompass Group Introduces SafeCare Disposable Isolation Gowns New SafeCare disposable isolation gowns from Encompass Group LLC are designed for performance and comfort under pressure. They are generously sized for a universal fit and quality infection control barriers help ensure safety for patients, visitors and health care providers. Made of SMS and PE-coated SMS fabric, the gowns also feature an elastic wrist and thumb loop for maximum comfort and a secure hold. • For more information, visit www.encompassgroup.net.

10 | OR TODAY | SEPTEMBER 2018

Mölnlycke has acquired SastoMed GmbH, a German wound care products company. The deal adds products to Mölnlycke’s wound care portfolio including Granulox, a haemoglobin-based topical oxygen therapy spray that is sprayed on wounds for faster wound healing, and Granudacyn, a hypochlorous wound irrigation solution for cleaning, moistening and rinsing of acute, chronic and contaminated wounds, and first and second degree burns. ‘Today, chronic wounds, such as foot ulcers, have a higher mortality rate than both breast cancer and prostate cancer and the real burden of ulcers is not yet fully known or understood. Mölnlycke will now be able to offer health care professionals – and patients – solutions to support both active and passive healing. We can therefore offer a holistic approach to wound treatment through our portfolio,” says Mölnlycke CEO Richard Twomey. With the acquisition of SastoMed GmbH, Mölnlycke adds another award-winning product to its wound care offer. Earlier this year, Granulox won the 2018 Innovation Award at EWMA (European Wound Management Association) Congress in Krakow thanks to its ability to advance the healing process. Studies report that Granulox can reduce total costs of initial diabetic foot ulcers treatment by about 60 percent a year. Over the past few years, Mölnlycke has invested in organic research and developement to meet customer needs and bring innovative products to the market. The acquisition complements this investment with new technology and capabilities, further accelerating Mölnlycke’s potential for product innovation. •

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INDUSTRY INSIGHTS

news & notes

HNT Medical to Manufacture Surgiline OR Table in USA HNT Medical has been serving physicians’ needs by manufacturing customized medical equipment and disposable products since 1997 and has announced a partnership with Bicakcilar to manufacture its Surgiline Series surgical tables in the USA. “The durability, sturdiness and flexibility of the Surgiline Series will be a great addition to the market through the joint efforts of HNT Medical and Bicakcilar,” according to a news release. “HNT Medical manufacturing facilities are FDA-registered with full compliance to the quality system regulations (QSR) and certain UL-Certified products. They offer custom solutions for physicians with their specialties that include: OR table/surgical table, dialysis and blood draw chairs, ENT chairs, dermatology, gynecology, procedure, and podiatry chairs.” The exclusive contract to manufacture Bicakcilar’s surgical tables provides extensive technological advances for HNT Medical. “I’m honored and very happy to have this opportunity,” said Jonathan Powell president of HNT Medical. “HNT Medical has strived to provide a complete platform of medical chairs and tables manufacturing for a global market. From our pediatric Zoopals tables to our physician-specific exam chairs, NITROCARE hospital beds and now the Surgiline Surgical Table with Bicakcilar, we now cover the full-spectrum of medical community equipment needs. We are truly excited for a long-term partnership and growth with Bicakcilar.” Souheil ElHakim, CEO of Bicakcilar added, “We are very excited to step into the North American market as we set our goals for Strategy 2020. This is a great starting point and opportunity for us on the way to become a truly global brand as we enhance our surgery portfolio. Our partnership with HNT Medical is invaluable and we know that with their strong presence and knowledge of the market, jointly, we will keep growing into the future.” •

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Key Surgical Announces Acquisition to Expand Product Offering Key Surgical LLC, a global provider of sterile processing and operating room supplies, announced that it has acquired Sarasota, Fla.-based Encompas Unlimited to expand the company’s endoscopy product offering. Encompas is the second acquisition that Key Surgical has completed since it merged with Interlock Medizintechnik GmbH last year to become a provider to hospitals and surgical centers around the world. Founded more than 30 years ago, Encompas specializes in manufacturing, assembling and distributing a range of endoscopy accessories and supplies. Key Surgical will incorporate Encompas’ endoscopy supplies into its portfolio of more than 3,000 products used by hospitals and surgery centers for patient procedures, as well as to clean and sterilize surgical instrumentation. Brian O’Connell, president and chief operating officer, Key Surgical, said, “We are excited to broaden our offering to our customers and their patients with the addition of Encompas. The company has an excellent reputation for offering high-quality products, and we are excited to build on Key Surgical’s existing presence in the growing endoscopy market.” As of the end of July, Encompas became a part of Key Surgical and its products are available directly from Key Surgical. •

SEPTEMBER 2018 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

Masimo Releases New Vital Signs Check Application Masimo has announced the worldwide release of the Vital Signs Check Application, an integrated patient data collection and workflow application for the Masimo Root patient monitoring and connectivity platform. Vital Signs Check, available for new and existing Root customers through a software upgrade, augments Root’s versatility by helping to automate hospital vital signs testing workflows. Root is an expandable platform that integrates an array of technologies, devices and systems to provide multimodal monitoring and connectivity solutions – in a single, clinician-centric hub. Root’s plug-and-play expansion capabilities allow clinicians to simplify patient monitoring by bringing together advanced rainbow SET Pulse CO-Oximetry, brain function monitoring, regional oximetry, capnography and vital signs measurements on an easy-tointerpret, customizable display, empowering clinicians with important information for making patient assessments. Root Vital Signs Check allows clinicians to streamline vital signs measurement workflows and optimize patient data management through: • Automated patient association, with the ability to quickly associate clinicians with their measurement sessions and patients with their data using barcode scanning or a drop-down menu that pulls data from a hospital’s

12 | OR TODAY | SEPTEMBER 2018

HL7 Admit Discharge Transfer (ADT) system. • Centralized data collection using a single device. Root, with the use of its optional roll stand, serves as a convenient, mobile data collection point for a variety of integrated measurements, including oxygen saturation (SpO2), pulse rate, respiration rate, noninvasive hemoglobin (SpHb), and noninvasive available, saving time and minimizing blood pressure and temperature (inthe need for manual documentation. cluding, in the U.S., non-contact therLocal storage, coupled with unique pamometry via the newly announced tient identifiers, also allows clinicians TIR-1). Clinicians can also enter up to to trend and review progress over time 30 additional measurements for imfrom the bedside, which may help to mediate documentation and validation identify patterns of deterioration. at the patient’s bedside, configured for “From the operating room to the emereach care area’s protocols. gency room, from the ICU to the med-surg • Early Warning Scores. Configurable unit, Root is streamlining care, simplifyearly warning scores (EWS) can be ing access to critical data, and improving calculated using up to 14 Root-mea- hospital workflows, all so that clinicians sured and manually entered concan stay focused on their patients,” Masimo tributors, as determined by hospital founder and CEO Joe Kiani said. “With protocol. the Vital Signs Check app, Root’s utility • Immediate electronic charting at is further enhanced, taking an important the bedside, with the ability to send aspect of hospital care – the repetitive, complete, comprehensive data to the data-and-labor-intensive measurement of hospital electronic medical record patient vitals – that can benefit greatly from (EMR) with the touch of a button. If automation and bringing it in line with the a network connection is interrupted best that modern technology offers.” • or only available at an access point, Root can store up to 1,000 sessions For more information, and automatically push all data to the visit www.masimo.com. EMR once network access becomes

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INDUSTRY INSIGHTS

news & notes

AAAHC Toolkit Focuses on Avoiding Errors, Adverse Events A key strategy in avoiding adverse drug events is making a list of medications a patient is currently using and comparing it to a “single source” document, also known as medication reconciliation. Medication errors are a top concern in both inpatient and outpatient settings – where medication lists can quickly become inaccurate when patients are referred or transitioned to other providers or specialists. To educate ambulatory health care organizations on how to avoid preventable adverse drug events, AAAHC has released a new toolkit outlining the importance and the essential elements of medication reconciliation. Medication errors account for an estimated 3.5 million physician office visits and 1 million emergency room trips per year. Affecting more than 7 million patients, preventable medication errors rack up nearly $21 billion in associated health care costs annually. When providers fail to adequately monitor medications and check for adverse events or nonadherence with prescriptions, prevent-

able readmissions increase. These errors can occur during routine exams, admissions or post-discharge, emphasizing the importance of implementing a consistent medication reconciliation protocol. The AAAHC toolkit outlines essential elements every complete medication reconciliation process should have for both primary care and ambulatory surgical/procedural settings. The toolkit also provides sample medication reconciliation forms for primary care and ambulatory surgical/ procedural providers to use or modify to meet their specific needs. • The Medication Reconciliation Toolkit is available for purchase at www.aaahc.org/institute. For more information on medication reconciliation, other AAAHC resources or accreditation programs, visit www.aaahc.org.

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SEPTEMBER 2018 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

IMP Promotes Universal Lateral Positioner InstruSafe Launches New Trays for da Vinci System InstruSafe Instrument Protection Trays by Summit Medical, an Innovia Medical Company, announced the release of eight new trays designed in collaboration with Intuitive Surgical to accommodate the newest da Vinci Surgical System Instrumentation. The instrumentation, which is identified as the da Vinci SP Surgical System, was launched on May 31. “We have been designing trays for Intuitive Surgical products since 1999, and actively collaborating with them since 2009,” said Marcus Super, director of InstruSafe sales and marketing. “The long-standing relationship we have with the company, and the confidence they have in the InstruSafe brand, is a testament to the quality of our product and its ability to provide the highest level of protection to the instrumentation it holds.” InstruSafe Trays provide 360 degrees of protection for instruments during sterilization, transportation and storage. They are validated for steam sterilization in the sterile wrap configuration for the da Vinci SP instrumentation. The trays for the new system’s instrumentation are now available for purchase and consist of instrument, procedure and accessory trays, each holding a range of one to six instruments. All of the trays in the newly developed suite have been designed specifically for da Vinci SP Surgical System instrumentation. • For more information about InstruSafe Instrument Protection Trays, visit www.instrusafe.com.

14 | OR TODAY | SEPTEMBER 2018

Innovative Medical Products Inc. ran a recent promotion, “Retire the McGuire,” calling on owners of the original McGuire Pelvic Positioner to turn in their dated hip positioners toward purchase of a new Universal Lateral Positioner (ULP), the legacy successor to the McGuire device. The campaign reminded customers that IMP itself was created upon its incorporation in 1983, after establishing a contract to manufacture and sell the McGuire positioner. The McGuire device was designed by Wisconsin surgeon, Dr. George McGuire. “The McGuire was the first hip positioner and clamping device made specifically for rigid fixation of the pelvis in total hip replacement,” noted Innovative Medical Products Vice President Earl Cole. “To this day we still utilize all of the original concepts that made that device effective, which means the legacy of the McGuire hip positioner continues 34 years after millions of total hip procedures, and without one reported issue. In other words, we might be retiring the McGuire positioner but certainly not its legacy.” The Universal Lateral Positioner was the first hip positioner device designed for different patient anatomies. Utilizing its patented hyperflexion plate with its swivel arms on the anterior support column, it allows additional space up to 120 degrees of flexion during range of motion (ROM) testing. The ULP’s swivel arm, dense-foam, contour lumbar pads conform completely to patient anatomy, improving stability and pressure distribution. The positioner’s five-groove base plate provides multiple locations for accessories and increases options to position attachments, not to reposition patients. The IMP solution also provides multiple component options for standard and large ULP positioners with a baseplate that comes in two sizes, a standard 22 inches and a large 25 inches for obese patients. The ULP also comes with a storage case that keeps positioning components organized, improving OR efficiency. •

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SOMAVAC Medical Solutions Receives FDA Clearance of Wearable PostSurgical Pump SOMAVAC Medical Solutions Inc. has announced U.S. Food and Drug Administration (FDA) clearance of SOMAVAC 100 Sustained Vacuum System, a closed suction drain device. The SOMAVAC 100 is a low-profile, user friendly, wearable medical device that applies sustained vacuum to a closed wound following surgery to remove fluid effectively and reduce the risk of seroma, and is the only patient-centric, valuebased alternative to the suction bulbs used in closed suction drains. SOMAVAC 100 was designed to replace the legacy technology of using suction bulbs with surgical drains, which has seen little innovation or advancement since the 1970s. In addition to its health benefits, the drain and pump can be discretely worn under clothing which aids in helping patients return to normal activities while recovering. “This FDA clearance represents a critical milestone for SOMAVAC and provides a meaningful advancement in post-surgical care, offering patients the opportunity to recover with dignity at home after major surgeries,” said Esra Roan, PhD, chief executive officer of SOMAVAC Medical Solutions. “We are excited about receiving our clearance from the FDA for this device so that our technology can begin to improve patients’ recovery after surgeries.” The SOMAVAC 100 is indicated for use in a range of surgeries which lead to large surgical flaps requiring drains, such as abdominal surgery, mastectomy, cosmetic surgery, hernia surgery, orthopedic procedures, etc. •

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COMPANY SHOWCASE

oneSOURCE

company

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The oneSOURCE HTM Biomedical Database The Most Complete Online Collection of Biomedical Equipment Maintenance Documents

A Technology Solution for Managing Critical Biomed Equipment Information With the oneSOURCE HTM Biomedical Database, healthcare technology management (HTM) managers will spend far less time and energy obtaining, verifying and managing biomedical equipment preventive maintenance and related documents. Instead, they’ll be able to focus on their true mission – efficiently maintaining this equipment to promote optimal patient care and safety.

The oneSOURCE HTM Biomedical Database HTM managers will have 24/7 access to service and maintenance manuals from thousands of manufacturers. And the database is growing constantly as our team obtains new and updated material on behalf of our customers. With this kind of critical information at their fingertips, technicians in every key department of the facility

16 | OR TODAY | SEPTEMBER 2018

will save time and increase efficiency. They’ll be referring to the most recent information about the complex biomedical equipment in their care … information related to: • Maintenance • Testing • Parts breakdowns • Troubleshooting • End of life equipment documentation • Repair Facilities also can use the oneSOURCE HTM Biomedical Database to securely store their own alternative equipment maintenance (AEM) program guidelines and proprietary or purchased documents, making this a secure, customized repository for all their biomedical equipment maintenance information. No more central storage headaches. No more time spent contacting manufacturers for manuals and updates. It’s all online, ready for review or download. WWW.ORTODAY.COM

User-Friendly Features The oneSOURCE HTM Biomedical Database interface (also available as an Android and Apple app) is carefully designed with intuitive user features and functionality. • Search by catalog number, manufacturer or equipment description • Maintain a list of frequently/recently used documents for even quicker access • Establish Favorites lists, sorting by technician, equipment type, maintenance schedule or other fields • Enter notes and customized instructions that will be shared throughout the facility • Click on the Table of Contents links in the manuals to go directly to that section • Access summaries of the pertinent cleaning, decontamination, assembly and sterilization information contained in the original documents • Download material from the database in Adobe files for emailing and printing • Interface with CMMS companies such as AIMS, EQ2 and MediMizer We work with each customer to customize their Biomedical Database’s content and features. One subscription provides access to technicians and other users throughout the facility – from Central Sterilization to Infection Control to Risk Management.

Promoting Compliance Adhering to these manufacturer preventive maintenance guidelines and also documenting your technicians’ ready access to this information can be a key element in meeting the compliance and certification standards established by organizations such as: • Centers for Medicare and Medicaid Services (CMS) • The Joint Commission (JC) • The Joint Commission International (JCI) • Accreditation Association for Ambulatory Healthcare (AAAHC)

Partnership with Manufacturers More and more manufacturers are seeing the value of working with oneSOURCE to efficiently send new and updated biomedical equipment preventive maintenance information for their customers. We upload these manufacturer documents exactly as we receive them. Manufacturers have complete control of their information, working through their own secure portal to verify and review their material. Some manufacturers choose to charge for these documents or require a facility to prove training before they release them. In these cases, the facility can provide the documents to us once they receive them and we upload them to the facility’s secure portion of the database, accessible only to them. If you would like to manage your critical responsibilities more efficiently with 24/7 access to the oneSOURCE HTM Biomedical Database service, contact us at 800-7013560 or if you are interested in a free webinar, email us at contact@onesourcedocs.com.

what clients are saying about oneSOURCE “The oneSOURCE Biomed Database is very helpful to our clinical team. The oneSOURCE interface with AIMS is a huge time saver for our technicians. We don’t have to search at our site or request manuals from the manufacturer. All the data we need for compliance is there at a click of the mouse.” – Data Integrity Team Manager

About Us Formed in 2009, Best Practice Professionals Inc. (dba oneSOURCE Document Management Services) also offers database services featuring the most complete collections of: • Instructions for Use documents from medical device manufacturers • SDS/MSDS and Instructions for Use documents from dental equipment, instrument and consumables manufacturers At oneSOURCE, we work with outstanding healthcare technicians every day – from our own employees who manage this document service to the facility-based HTM professionals who need this information at their fingertips. www.onesourcedocs.com 800-701-3560 | contact@onesourcedocs.com WWW.ORTODAY.COM

SEPTEMBER 2018 | OR TODAY |

INDUSTRY INSIGHTS webinar

UVC Disinfection Webinar Delivers Valuable Information Staff report

n OR Today webinar sponsored by Tru-D provided expert insights for attendees. The webinar “Real-World UVC Disinfection Success: A Case Study With Phelps Memorial Health Center” presented by Alice Brewer, Director of Clinical Affairs at Tru-D SmartUVC and Tesha Broadfoot, Quality Leader at Phelps Memorial Health Center, Nebraska, discussed the effectiveness of UVC disinfection and TruD’s unique technology. It also examined how Phelps Memorial Health Center has successfully implemented UVC disinfection for real-world results.

Attendees shared positive reviews regarding the webinar in a follow-up survey. “Informative presentation that highlighted the importance of staying up to date with current technologies to provide better patient care,” said K. Hayden, OR RN. “Today’s webinar about UV cleaning and how another hospital has taken steps using UV to decrease hospital-acquired infections gave me some new ideas for actions at my hospitals. Hearing from others with similar issues who take varied approaches is a great way to learn,” said J. Shivers, Director of EVS. “Presenters were very knowledgeable and the content was very relevant to today’s OR issues. I am unemployed, but find OR Today a great resource to stay current on my educational needs,” said E. Anderson, RN. “Excellent webinar, very “Very informative webinar about this up-and-coming informative, speakers cleaning method,” said D. Pullman, CRNFA. were excellent and gave “Excellent webinar, very informative, speakers were expertinent and very interesting cellent and gave pertinent and very interesting information,” information.” - S. Ellis, RN Quality said S. Ellis, RN Quality.

18 | OR TODAY | SEPTEMBER 2018

The overall webinar series also received praise from attendees. “OR Today webinars provide valuable information for a fairly novice OR supervisor,” said J. Brumbaugh, OR Supervisor. “It is very convenient to obtain CE per webinar technology instead of having to travel and pay for tuition, etc. Your topics are current, and are easy to listen to. Keep up the good work,” said M. Blacharski, Retired RN. “OR Today’s webinar series is always very interesting and usually pertinent to my role and facility. Even when the topic is not necessarily something that will benefit my facility or my role, I still learn so much from participating in the webinars. I also find the webinars are always up-to-date and current to what is happening in the ORs and hospitals in today’s health care environment,” said S. White, RN, CNOR, CIC. For more information, visit ORToday.com. Sponsored by:

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IN THE OR

market analysis

Patient Safety Remains Key Market Segment Staff report February 2018 report from ResearchAndMarkets.com titled “Patient Safety in Healthcare, Forecast to 2022” estimates that various adverse events put an additional cost burden of $317.9 billion on hospitals across the U.S. and Western Europe, adversely affecting 91.8 million patients and leading to 1.95 million deaths in 2016. The cost burden is expected to increase at a compound annual growth rate (CAGR) of 3.2 percent to reach $383.7 billion by 2022.

The ResearchAndMarkets.com study is a comprehensive analysis of 30 of the most pressing patient safety adverse events affecting patients, care givers and health care organizations across the globe. The study measures the current and forecast cost impact, number of incidences and mortality of individual adverse events. It goes on to list the top adverse events, current investment trends and forecast stakeholder interests. It also analyses the current competitive environment, most impactful vendor solutions addressing the top patient safety issues and their future market potential. The ResearchAndMarkets.com study also highlights some of the most innovative and promising solutions capable of disrupting the market as well as convergence of new technologies entering the field. It concludes with its five most-compelling future growth opportunities, key strategies for growth and implementation challenges. WWW.ORTODAY.COM

Some key areas of discussion within the report include: • Patient Care Management (medication safety, wrong patient/site/indication (WPSI) events, patient falls, pressure ulcers, antibiotic resistance, patient handoff safety, maternal death and diagnostic safety) • Health IT Management (EHR/ EMR Safety, alarm fatigue, lack of patient engagement, hospital outcomes data transparency, protected health information (PHI) compromise, unnecessary emergency department (ED) admissions, and medical device cyber-security) • Surgical Care Management (CAUTI, vascular catheter infections, HAP/ VAP, venous thromboembolism, surgical site infections (SSI), sepsis, air embolism, foreign object post-surgery, off-label drug/device usage) • Environment and Workforce Management (burns/thermal injuries, anesthesia safety, electrocution, healthcare worker (HCW) immunization, occupational physical safety hazards, and psychological health of HCW) A recent Frost & Sullivan’s analysis on patient safety in health care covers innovative and promising solutions, convergence of new technologies, key market participants and more. “In the next four years, adverse patient safety events in the United States and Western Europe such as healthcare associated infections (HAIs), sepsis, medi-

cation safety, pressure ulcers, diagnostic errors, antibiotic resistance and hand hygiene non-compliance will drive an estimated health care cost burden of $383.7 billion,” according to a press release regarding the Frost & Sullivan report. “While some adverse events, such as medication safety and hand hygiene non-compliance, are relatively well addressed by current industry solutions, under-penetrated areas such as antibiotic resistance, pressure ulcers, sepsis and unnecessary ED (emergency department) admissions will be the high opportunity growth areas for future.” In the next four years, Frost & Sullivan predicts the following developments: • Patient safety transitioning from an ancillary to a core value proposition for care providers • High adoption of patient and asset tracking as well as identification technologies • Increased consolidation in the industry with large med-tech companies going for provision of targeted solutions for key unmet need areas • Significant use of remote health care technologies such as Internet of Medical Things (IoMT) coupled with increasing health care data exchange, leading to disproportionate increase in cybersecurity risks such as protected heath information (PHI) compromise and medical device/ implants data breach • Collaboration to develop guidance documents and draft policies for best practices on risk mitigation.

SEPTEMBER 2018 | OR TODAY |

IN THE OR

product focus

3M Tegaderm Antimicrobial Dressings 3M has introduced 3M Tegaderm Antimicrobial I.V. Advanced Securement Dressing and 3M Tegaderm Antimicrobial Transparent Dressing to enhance its offerings for PIV maintenance solutions. The new 3M antimicrobial PIV dressings integrate CHG transparently throughout the adhesive to suppress normal skin flora regrowth on prepped skin for up to 7 days, better than non-antimicrobial dressings. The dressing’s transparency provides clinicians continuous site visibility, which enables early identification of complications at the insertion site. Tegaderm Antimicrobial I.V. Advanced Securement Dressing is designed to minimize catheter movement and dislodgement. • For more information about 3M offerings for PIV care and maintenance, visit 3M.com/PIVcare.

Snowden-Pencer 3mm Laparoscopic Instruments Developed with leading surgeons for more than two years, BD’s new portfolio of Snowden-Pencer 3mm laparoscopic ergonomic take-apart instruments are designed for microlaparoscopic surgery. BD’s 3mm instruments enable surgeons to perform procedures known to provide patients with a virtually scar-less procedure, reduce post-operative pain, improve post-operative appearance and reduce hospital stays.1 The jaw lengths and openings of the devices are closely scaled to those of standard laparoscopic instruments, providing surgeons with a less invasive surgical approach without compromising instrument functionality. The modularity and reusability of the devices offer a costeffective alternative to other microlaparoscopic options. • 1 Redan JA, Humphries AR, Farmer B, et al. Big operations using mini instruments: the evolution of mini laparoscopy in the surgical realm. Surg Technol Int. 2015;27:19–30.

22 | OR TODAY | SEPTEMBER 2018

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IN THE OR

product focus

Checklist Boards Corp. Checklists

Checklists reduce errors in operating rooms. A time-out must be facilitated by a checklist and occur immediately prior to the start of each procedure. These Checklist Boards are customized to address site specific needs, from pre-op into surgery through recovery. Upon completion of each task, a slider is moved from red to green creating an audible click. Checklist Boards provide a backup to human memory during routine and high-stress situations reducing costs by error prevention. •

Encompass Group

PulSTAR Logix IPC System Surgical Safety Checklist Patient:_____________________________________________________________________ Date:_____________ Procedure:_____________________________________________________________________________________ ______________________________________________________________________________________________ SURGICAL SIGN IN

SURGICAL TIME OUT

Green Red Confirmed or N/A Not Confirmed

RADIOLOGY TIME OUT

Green Red Confirmed or N/A Not Confirmed

Team introduces themselves (including roles)

Team introduces themselves (including role)

Validate correct patient

Correct Patient (using 2 identifiers) Armband checked and validated

Validate the area requiring radiology exam

Surgical procedure to be performed matches the consent

Correct site and/or side (site mark visible after draping)

Any other issues/concerns?

Allergies

Correct Procedure

Verification of dosimeter badge and lead apron. N/A

History and Physical Complete/Current

Correct Position if applicable

VTE Prophylaxis

Appropriate Antibiotic selected and started within one hour prior to surgical incision

Name of procedure validated and documented correctly

Review of Critical Information

Safety strap on

All counts completed and reconciled

Diagnostic Tests Available

Verification of dosimeter badge and lead apron. N/A

Specimens labeled correctly

Sterility validated including indicator results

Fire Risk Score: 1- low 2-low potential for high 3-high risk

Disposition of unused blood products

Implants, devices, special equipment available and verified as applicable

All elements resolved

Equipment issues addressed

Site marked

Are we ready to start?

Documentation and verification of wound classification Communicate key concerns for the patient recovery and hand-off report

Imaging available Aspiration risk

SURGICAL DEBRIEFING

Notes:

Blood product requirements Risk hypothermia Pre-anesthesia assessment complete Anesthesia safety check complete Beta blockers are current if applicable For best results use only Checklist Board™ markers, other markers may stain the surface. Use a clean dry cloth to wipe after every use, do not use solvents. Order markers and Checklist Boards™ at 585-586-0152 or checklistboards.com.

8561CP40 v2

The PulSTAR Logix Intermittent Pneumatic Compression (IPC) System is the latest addition to the StarSystem integrated suite of DVT prevention products by Encompass Group LLC. The system’s components and operation were designed to drive patient compliance and provide ease of use for clinicians. The PulSTAR Logix pump is lightweight; weighing less than 5 pounds. It is extremely quiet in operation, and has limb wrap options for both calf and foot therapy. The digital controller interface allows for single or dual limb operation. The calf compression delivers 40mmHg and the foot compression delivers 135mmHg. Therapy can be applied to the foot, the calf or calf-andthigh combination with wrap garments sized S through XL. • For more information, visit www.encompassgroup.net.

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SEPTEMBER 2018 | OR TODAY |

IN THE OR

product focus

Halyard

Clear Sequence Kits Clear Sequence kits are a customizable product delivery mechanism and aseptic drape system. The Kits are sequentially designed to help promote consistent compliance during the patient’s episode of care, specifically in the removal and reapplication of a central line dressing change. The patent-pending kits reduce the risk of microbial and other site contamination by serving as a protective barrier that separates the removal portion from the application phase of the procedure. They are easy to use to promote protocol adherence, reduce waste and provide an unobstructed view of all components while maintaining a sterile field in a limited workspace. •

Key Surgical

Needle Counters Key Surgical Needle Counters facilitate the count of various used sharps and needles in an operating procedure. Integrating a solution like this can help reduce the risk of retained objects inside a patient. Sold sterile and ready-to-use, features include easy open latches, a variety of styles (single or dual magentic, foam block, magentic and foam) and red-colored containers to signify biohazard material. • For more information, visit www.keysurgical.com.

24 | OR TODAY | SEPTEMBER 2018

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1. Mullen A, et al. Perioperative participation of orthopedic patients and surgical staff. AJIC, 2017: Vol 45, Issue 5, 554 - 6. 2. Steed L, et al. Reduction of nasal Staphylococcus aureus carriage. AJIC, 2014: 42(8): 841-6. ©2017 Global Life Technologies Corp. All rights reserved. Made in USA. Nozin®, Nasal Sanitizer®, 360™, Leader in Nasal Decolonization are trademarks of Global Life Technologies Corp. Nozin® Nasal Sanitizer® antiseptic is an OTC topical drug and no claim is made that it has an effect on any specific disease.

IN THE OR

continuing education

IN THE OR

CE567

continuing education

Malignant Hyperthermia Nancymarie Phillips, PhD, RN, RNFA, CNOR(E) Dawn Demangone-Yoon, MD

magine that you are an OR nurse assessing your first patient of the day. You help the patient to the OR and onto the table. Standard monitors are applied, and you note that this is a first surgery for the 30-year-old patient. He receives routine induction medications that include fentanyl IV (Actiq), propofol (Diprivan), and succinylcholine (Anectine). Intubation is uneventful. The patient is placed on air and oxygen at 50% flow for each, with desflurane (Suprane) 6% inhalational agent. Within minutes, the anesthesia provider notes muscle rigidity in the patient and an increase in exhaled carbon dioxide, heart rate, and blood pressure. The provider suspects malignant hyperthermia based on these initial findings. As a vital part of the team, what will you do to help? What is the best plan of action? How can you help save this patient’s life?

Definition and Etiology Malignant hyperthermia is a hypermetabolic syndrome primarily encountered intraoperatively after the administration of a triggering anesthetic agent. In rare cases, MH can manifest within one hour postoperatively in the postanesthesia care unit. Dental offices and EDs might administer some of the triggering agents and should be alert to the potential for a crisis. MH is triggered by depolarizing neuromuscular agents, such as succinylcholine, or by a volatile WWW.ORTODAY.COM

halogenated anesthetic agent, such as ether, enflurane, methoxyflurane, desflurane, sevoflurane (Ultane), or isoflurane (Forane).1 MH is an autosomal dominant pharmacogenetic clinical syndrome during which a hypermetabolic state develops and becomes a life-threatening emergency.1,2 The patient’s body becomes hyperthermic because of increased metabolic activity within the skeletal muscle. Exposure to one or more of the triggering agents causes a rapid intracellular and extracellular imbalance of calcium that leads to significant energy use and heat production due to continued muscle contraction, and at the cellular level, as continuing attempts to correct the hypercalcemia are made.3 Calcium is an extracellular ion of the soft tissue that is necessary for nerve impulse transmission, muscle contraction, cardiac function, and blood coagulation. The increased amount of intracellular calcium causes sustained muscle rigidity that increases metabolism in both oxygen-dependent and independent pathways, increasing overall oxygen consumption as well as leading to severe lactic acidosis. Lactic acidosis occurs when the body obtains energy by breaking down glucose reserves without the use of oxygen. As the levels of lactic acid increase, the muscle membranes break down, releasing myoglobin and potassium stores. The elevated myoglobin, also termed rhabdomyolysis, can lead to kidney damage. And, as extracellular potassium increases, high levels may predispose patients to cardiac conduction abnormalities and sudden death.1-3 The etiology of MH, in most cases, is a defect of the genetic receptor that controls calcium release from the sarcoplasmic retic-

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

Goal and objectives The goal of this continuing education program is to provide OR nurses, physicians, and surgical technologists with information about malignant hyperthermia, including perioperative signs and management of the patient. After studying the information presented here, you will be able to: • Identify patients at risk for malignant hyperthermia • Differentiate the early and late signs and symptoms of malignant hyperthermia • Describe diagnosis and treatment of malignant hyperthermia

SEPTEMBER 2018 | OR TODAY |

IN THE OR

continuing education ulum of the muscle cell wall. No single gene mutation causes MH susceptibility. However, more than 170 variations in the ryanodine receptor 1 gene (the intracellular calcium channel gene, also called RYR1) have been linked to MH susceptibility.2-5

History MH was identified in the 1960s in Australia by researchers when a 21-year-old patient told his physicians he was more concerned about receiving anesthesia than having surgery for his broken leg. Ten close relatives had died when under anesthesia during minor procedures. The anesthesiologist thought the deaths were caused by ether, so he gave the young man a new anesthetic gas, halothane. The patient became cyanotic and displayed erratic vital signs, including hyperthermia. Monitoring end-tidal carbon dioxide and body temperature were not the standard of care at that time. The anesthesiologist treated the patient symptomatically and packed him in ice. The patient became the first recorded person to survive an MH crisis. One of the researchers traced the autosomal dominant inheritance of the familyâ&#x20AC;&#x2122;s severe reaction to anesthesia over three generations. He later published his findings in The Lancet.6 The patient had surgery later under spinal anesthesia without incident. Malignant hyperthermia does not discriminate among races, and all ethnic groups are affected in all parts of the world. Reactions develop more frequently in males than females by a 2-to-1 ratio. MH is not X-linked as are many other muscular diseases, such as muscular dystrophy. The incidence of MH reactions ranges from 1 in 100,000 for adults to 1 in 30,000 pediatric anesthetic administrations, with the prevalence of the genetic abnormalities being as great as 1 in 2,000 people. This is about 500 to 800 surgical cases per year. The true prevalence is difficult to define because of unrecognized mild or aborted reactions. Some patients have

28 | OR TODAY | SEPTEMBER 2018

had previous surgery under general anesthesia without any reactions.2 The highest incidence of MH is in males with a median age of 39.2 Patients who have an increased muscular build or muscular deformity are associated with a greater risk of death during an MH crisis. Earliest studies concluded that mortality ranged between 70% and 90% before treatment options and monitoring devices for carbon dioxide levels were developed. Later studies showed that with appropriate diagnosis and treatment, the mortality rate fell to around 5%.7 Animal studies have shown that some genetically similar mammals, particularly swine, display hypermetabolic symptoms similar to those in humans when exposed to triggers, such as depolarizing neuromuscular blockers and volatile anesthetic gases.1,2 Nondepolarizing neuromuscular agents, barbiturates, sedatives, and nitrous oxide do not trigger the syndrome and can be used to perform a surgical procedure without danger. These anesthetic agents and drugs keep the patient anesthetized for surgery and allow for endotracheal intubation, which is frequently required. Local and regional anesthetics are also safe to use.1

Signs and Symptoms The most common initial sign of acute MH is an unexplained rise in end-tidal carbon dioxide, known as hypercarbia. Carbon dioxide levels rise above the normal 35 to 45 mmHg range despite increasing the respiratory rate on the ventilator settings. This rise in carbon dioxide of more than 60 mmHg is a hallmark indicator of MH.8 Muscle rigidity after the administration of a depolarizing agent, especially masseter spasm or trismus (contraction of the jaw muscles), is another potential sign of MH. Trismus can be present in the absence of MH and is not uncommon in small children.2 Unexplained tachycardia and tachypnea are also early signs of MH. Ventricular fibrilla-

tion, a lethal heart dysrhythmia seen on electrocardiogram, can develop within minutes of the onset of MH and may rapidly lead to death.2,8 Later signs of MH include metabolic acidosis, hyperthermia, and evidence of rhabdomyolysis. Rhabdomyolysis is the catabolism (breakdown) of skeletal muscle associated with excretion of myoglobin (a protein in muscle fibers) in the urine.8 This is reflected by dark brown urine caused by myoglobinuria with hyperkalemia (increased potassium), increased myoglobin and total creatine kinase (CK) levels in blood samples, resulting from muscle membrane breakdown. The myoglobin in the urine causes damage to the renal tubules and ultimately causes renal failure.2,9 Arterial blood gas analysis and lab findings reveal metabolic acidosis. Severe hyperthermia (core temperature greater than 104 F [44 C]) results from a marked increase in oxygen consumption and increased carbon dioxide production during sustained muscular contraction and is a later sign of MH.10 Patients exposed to extreme body temperature elevation for prolonged periods of time experience more central nervous system (CNS) complications postevent.10 Vasoconstriction associated with protracted muscle contraction causes widespread multisystem organ failure and disseminated intravascular coagulation (DIC). Further life-threatening conditions include congestive heart failure and compartment syndrome of the limbs secondary to profound muscle swelling.4,5

Diseases That Mimic Other diseases may be confused with MH, including trismus, central core disease, and neuroleptic malignant syndrome. Patients who exhibit trismus during induction of anesthesia are difficult to intubate, and loss of airway is a significant concern. The safest course of action is to assume that masseter spasm is due to MH and to postpone elective surgery under general anesthetic.1,2 WWW.ORTODAY.COM

IN THE OR

continuing education

Patients with masseter muscle rigidity are at greater risk for MH and should be tested. Because masseter muscle rigidity can be one of the initial signs of MH and half of the patients exhibiting masseter muscle rigidity are susceptible to MH, itâ&#x20AC;&#x2122;s better to stop the triggering agent and refer the patient for testing rather than continue to expose the patient to a possible MH incident.5 Central core disease is an inherited myopathy characterized by muscle weakness and hypotonia. Central core disease shares the same RYR1 gene mutations that MH exhibits, so patients with this disease are more susceptible to MH and should be treated carefully.4 Neuroleptic malignant syndrome is characterized by hyperthermia, muscle rigidity, autonomic instability, and altered consciousness in patients receiving antidopaminergic agents; it is caused by an imbalance of neurotransmitters in the CNS. Neuroleptic malignant syndrome shares many MH symptoms, including an elevated temperature (although mild), muscle rigidity, tachycardia, and elevated CK levels. Although this syndrome is separate from MH, many clinicians believe it is safer to avoid triggering agents in patients who have experienced neuroleptic malignant syndrome and thus the possible risk of MH.3,5 A variety of unusual conditions may resemble MH under anesthesia, including sepsis, thyroid storm, pheochromocytoma, and iatrogenic overheating from sources, such as warming blankets, heat lamps, and room temperature. MH is associated with more dramatic degrees of metabolic acidosis and venous desaturation (the decrease of oxygen in the venous blood) than these other diseases. Sepsis shares several characteristics with MH, including fever, tachycardia, and metabolic acidosis.5 In patients with poorly controlled hyperthyroidism, thyroid storm can cause tachycardia, tachydysrhythmias (especially atrial fibrillation), hyperthermia, and hypotension. Thyroid storm presents with hypokalemia and generWWW.ORTODAY.COM

ally develops postoperatively. Pheochromocytoma is a vascular tumor in the adrenal glands that produces and secretes norepinephrine and epinephrine. Itâ&#x20AC;&#x2122;s associated with dramatic increases in heart rate and blood pressure but not the rise in end-tidal carbon dioxide or hyperthermia as in an MH crisis. Iatrogenic overheating can come from sources such as heat lamps and humidifiers on the ventilator.4,5 After succinylcholine is administered, hyperkalemia can occur in young patients who have muscular dystrophy causing sudden cardiac arrest. Often confused with MH, sudden hyperkalemic cardiac arrest syndrome (increased levels of potassium that cause the heart to stop beating) occurs in young males during or shortly after receiving anesthesia.1,2 When exposed to anesthetic triggering agents, these patients can develop life-threatening potassium levels that lead to dysrhythmias and muscle catabolism. The rise in potassium after giving succinylcholine mimics the hyperkalemia associated with MH; therefore, it is best to avoid this drug with this patient population. These patients do not exhibit the classic rise in temperature or the marked muscle rigidity.1

At-Risk Patients The gold standard for diagnosis of MH in suspected or at-risk patients is the caffeine halothane contracture test (CHCT), which uses freshly biopsied skeletal muscle. It looks for contracture of muscle fibers in the presence of halothane or caffeine.5 The contracture test is performed after an open thigh muscle biopsy at a specially designated testing center. The fresh muscle is then exposed to increasing concentrations of halothane and caffeine within one hour of procurement. Because of the relative complexity of the test, only a few centers worldwide perform it. Four are in the U.S. and one is in Ontario, Canada. If a muscle biopsy cannot be performed, genetic analysis is a reasonable method by which to identify mutations of the

RYR receptor on the skeletal muscle. However, this is not always a conclusive method of diagnosing MH.5 Molecular genetics testing can be performed and sent by postal mail through several centers in the U.S. The Malignant Hypothermia Association of the United States lists locations for caffeine contracture and genetic testing for MH syndrome susceptibility at its website.5 DNA analysis, started in 1990, requires only a blood test and offers an alternative to CHCT. A negative DNA result, however, cannot be used alone to rule out susceptibility, because of the heterogeneity of the disorder, as well as dissimilarity within families.5 Because of the vast number of mutations that may cause MH, a specific family mutation must be identified to perform a genetic test. Molecular genetic testing via RYR1 screening analysis is in its beginning stages and will become more useful as additional research identifying causative mutations is completed. Testing is expensive and not always covered by insurance.5 A sample test from buccal cells, white blood and muscle cells, or other tissues can be used for mutation analysis of RYR1. There are now screens for many common mutations.4 Preoperative testing will be recommended for relatives of patients with known MH susceptibility and patients who experience suspicious clinical episodes of MH.2,5,11 Additional methods for testing have been used, including the insertion of a microdialysis catheter directly into muscle and testing B-lymphocytes that harbor RYR1 protein and release calcium when stimulated with caffeine. Neither has been sufficiently validated to be clinically useful. Susceptible patients should undergo testing to protect themselves and their families for future surgeries.2,5

Treatment Rapid, effective treatment of MH requires simultaneous actions by perioperative nurses and physicians. Early recSEPTEMBER 2018 | OR TODAY |

IN THE OR

continuing education ognition of MH is critical so treatment can be started expediently. Interaction among team members is crucial to manage an MH crisis. An important step in the immediate treatment of suspected MH is for the anesthesiologist to stop the administration of triggering agents and flush the ventilator with 100% oxygen.2,7,8,12 Every member of the surgical team should have a specific role in the effort to prevent confusion and duplication of the treatment efforts.12 The rapid administration of dantrolene sodium (Dantrium or Revonto) is the first-line medication administered. It is a direct-acting muscle relaxant.7 Introduced into clinical practice in 1979, dantrolene sodium continues to be the primary treatment for MH. The dantrolene sodium molecule is highly lipophilic (capable of dissolving in fats), which ensures a rapid crossing of the blood-brain barrier. It works by binding to the RYR1 receptor, thus inhibiting calcium release from the sarcoplasmic reticulum.7 Dantrolene sodium impairs the excitation-contraction coupling of the muscle cell membrane in muscular contraction. This leads to skeletal muscle relaxation and resolution of MH by restoring intracellular calcium balance and decreasing metabolism.7 Dantrolene sodium is supplied in 65 mL glass vials that contain 20 mg of lyophilized dantrolene sodium, 3 grams of mannitol (Osmitrol), and sodium hydroxide (for pH balance at 9.5), which are in a yellow powder form. Each vial requires 60 mL of sterile water as a diluent and requires vigorous shaking for several minutes. Only preservative-free sterile water should be used to reconstitute any form of dantrolene sodium because of the large quantities (around 700 mL) required for administration. It can take up to 36 vials of dantrolene sodium to stabilize and maintain the patient in crisis.2,7

30 | OR TODAY | SEPTEMBER 2018

The initial dose of dantrolene sodium is 2.5 mg/kg given IV every five minutes and then titrated to a suggested upper limit of 10 mg/kg as necessary based on lab results and clinical response.2,6,7 A response is evident with muscular relaxation, lowered end tidal carbon dioxide levels, and improvement in tachycardia.8 More may be given as needed. For example, a 70-kg person would require an initial dose of 175 mg, or nine vials, reconstituted every five minutes until MH symptoms subside, followed by repeated dosage as clinically indicated and/ or every 10 to 15 hours for 24 to 48 hours post-event.3 The weightbased dosage for pediatric patients is the same as for adults.2,7 A critical preoperative assessment factor is to document every patientâ&#x20AC;&#x2122;s weight in kilograms for rapid use in the event of need for emergency medication.2,7,11-13 Large quantities of reconstituted dantrolene sodium are needed; therefore, a central line may be necessary. Muscular contractions make peripheral veins unreliable and incapable of handling large infusions. Tissue necrosis can result if the drug extravasates from a peripheral IV line. Dantrolene sodium is continued at 1 mg/kg every four to six hours after the crisis is controlled and is continued for 72 hours after the episode.2,7,8 The perioperative nurse plays a helpful role in mixing this drug.12,13 Slightly warmed sterile water 96.8 F to 100.4 F (36 C to 38 C) can speed up the process. Dantrolene sodium is available in generic form, and the recommended shelf supply is 36 vials to stabilize and treat the patient during an MH crisis. More drug should be available to maintain the patient postoperatively in the ICU.2,7 In July 2014, the U.S. Food and Drug Administration approved a new form of dantrolene sodium, Ryanodex. It is supplied in 250-mg vials with 125 mg mannitol and requires only 5 mL

of room temperature, non-bacteriostatic sterile water for reconstitution, minimizing the risk of fluid overload.7 It can be mixed in 20 seconds by the same person who administers the drug. It is very fast with minimal risk of fluid overload. A central line may not be necessary. The drug must be administered via syringe and not incorporated into an IV bag infusion. This rapid-dissolving formula in one vial equals enough drug to stabilize the patient in crisis. Reconstituted dantrolene sodium should be protected from direct sunlight and must be used within six hours of mixing.2 Other diluents such as D5W or saline change the effects of dantrolene sodium. Lactated Ringerâ&#x20AC;&#x2122;s solution can increase metabolic acidosis and should not be used. Mannitol is included to protect the kidneys against myoglobinemia through diuresis (muscle damage causes myoglobin to be released into the bloodstream) and makes it easier to dilute the dantrolene sodium powder with sterile water. The use of additional mannitol during the crisis should take into account the amount contained in the dantrolene during dosage calculations.2,7 Dantrolene sodium should only be used in pregnant and lactating women if the benefits outweigh the risks.2 It crosses the placenta, and it also passes into breast milk. Although considered relatively nontoxic and having no absolute contraindications, dantrolene sodium is used with caution in patients with hepatic disease and the elderly because the liver metabolizes it.2,7 Another treatment measure is to cool the patient by all routes available if core temperature is greater than 102.2 F (39 C): instilling nasogastric lavage with iced solution; applying ice packs to the groin, axilla, and neck; and taking more aggressive measures as needed. Cooling procedures may conclude at a core temperature of < 100.4 WWW.ORTODAY.COM

IN THE OR

continuing education

F (<38 C).8 A Foley catheter should be inserted to monitor renal function, but should not be used for cooling irrigations, because the irrigant could be confused with output.2 The goal is to maintain urine output at 300 mL per hour.2 Labs and blood gases should be drawn to evaluate electrolytes, potassium, CK levels, and coagulopathies. Sodium bicarbonate may be administered in the setting of severe acidosis.8 The urine should be observed for myoglobin. Hyperkalemia should be treated by typical protocols including hyperventilation with 100% oxygen and the administration of bicarbonate, albuterol, glucose, and insulin IV as needed. Administration of calcium chloride or calcium gluconate should be considered in cases of life threatening hyperkalemia.8 CK levels track the severity of rhabdomyolysis, and repeated serum chemistry panels monitor renal function. Dysrhythmias, which might include sinus or ventricular tachycardia or ventricular fibrillation, should be treated symptomatically.2 Calcium channel blockers, such as verapamil (Calan, Covera), are contraindicated with dantrolene sodium as this drug combination might cause hyperkalemia.2,4 The Malignant Hyperthermia Association of the United States sponsors a 24-hour emergency hotline for medical professionals at 800-644-9737. Because many tasks and interventions must be completed rapidly, anesthesia staff should solicit extra help in caring for the patient.12 This is one area in which the perioperative team member is a tremendous asset in caring for the patient with MH. After team members control the crisis, they continue with monitoring and caring for the patient. The following interventions should be part of the patient’s care:2,4,8,13 • Because the patient is at risk for developing acute myoglobinuric renal failure, urine output should WWW.ORTODAY.COM

be maintained at 2mL/kg/hour by administering furosemide (Lasix) and mannitol and by providing IV fluids as needed. Ideal output is 300 mL per hour.2 • The perioperative nurse should monitor the patient’s core body temperature. Patients can become hypothermic because of cooling measures. If the patient is hypothermic (97 F [36.1 C] or less), a warming blanket or forced air warmer may be provided and IV fluids warmed before infusion, if necessary. • High or low potassium levels (outside the normal range of 3.5 mEq/L to 5 mEq/L) should be assessed to prevent continued heart dysrhythmias. IV potassium boluses may be given slowly for hypokalemia. Hyperkalemia may be lowered by typical protocols which may include administering glucose and insulin, sodium bicarbonate, albuterol and by increasing ventilation, which drives potassium back into the cell. • The patient should be observed in the ICU for 24 to 72 hours and evaluated for the need for continued mechanical ventilation and administration of maintenance dantrolene sodium. • Elevated liver function values are often observed 12 hours to 36 hours after the event, as well as DIC with coagulopathy, thrombocytopenia, and abnormal bleeding. • Postevent, the patient may complain of muscle pain and weakness caused by the prolonged contractions. Pain medication may be necessary.2 The patient and family should be referred for MH testing, and required forms should be submitted to the MH registry at the North American Malignant Hyperthermia Registry.2,11,13

Preventive Measures A thorough anesthetic history determines whether a patient or family member has experienced an MH episode in the past. If there is any likelihood of an episode, no triggering agents should be used, and tape should be placed over the inhalation agents in the OR. Regional or local anesthetics may be a more suitable choice for patients at risk for MH.1 Several types of patients should avoid triggering agents because of their health history, for instance, patients with Duchenne muscular dystrophy and central core disease should not receive triggering agents. Patients younger than age 12 are at risk for undiagnosed muscular dystrophy. Therefore, succinylcholine should be avoided in elective procedures to prevent a hyperkalemic response.1,2 All patients should have their core temperatures and end-tidal carbon dioxide monitored when under general anesthesia.2,10,11,13 The anesthesia machine should be prepared for a susceptible patient by flushing it with 100% oxygen at a rate of 10 L/minute for 20 minutes, using a fresh circuit and removing all the vaporizers. Examples of safe medications that may be used are barbiturates, benzodiazepines, opioids, and nitrous oxide.2,11-13 Malignant hyperthermia is a lifethreatening syndrome. Awareness of MH by all perioperative team members, from those working in the preoperative holding area to those in the PACU, is important in preventing negative patient outcomes.2,11,13 The preoperative nurse plays a crucial role in averting an MH crisis by interviewing every surgical patient for a personal and family history of MH. Perioperative and perianesthesia nurses can help patients by being knowledgeable of the signs and symptoms of MH, implementing evidence-based care, and educating patients and families about MH. Finally, the entire OR team should coordinate its efforts to work efficiently together to ensure the best possible care of their patients.2,11-13 SEPTEMBER 2018 | OR TODAY |

IN THE OR

continuing education EDITOR’S NOTE: Christina Emily Smith, MS, RN, CRNA, original author of this educational activity, has not had an opportunity to influence the content of this version. OnCourseLearning.com guarantees this educational activity is free from bias. Nancymarie Phillips, PhD, RN, RNFA, CNOR(E), is a retired professor of perioperative education for nurses and technologists at Lakeland Community College in 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, and Sigma Theta Tau Virginia Olsavsky Mentorship awards. Dawn Demangone-Yoon, MD, is director of CME for OnCourse Learning.

References 1. Safe and unsafe anesthetics. Malignant Hyperthermia Association of the United States Web site. http://www.mhaus.org/healthcareprofessionals/be-prepared/safe-and-unsafeanesthetics. Accessed April 5, 2017. 2. Phillips N. Berry and Kohn’s Operating Technique. 13th ed. St. Louis. MO: Elsevier; 2016:617619. 3. Zhou J, Diptiman B, Allen PD, and Pessah IN. Malignant hyperthermia and muscle-related disorders. In: Miller RD, Cohen NJ, Eriksson LI, et al, eds. Miller’s Anesthesia. Eighth Edition. Philadelphia, PA: Sauders; 2015. 4. FAQs: general MH questions. Malignant Hyperthermia Association of the United States Web site. http://www.mhaus.org/faqs/about-mh. Accessed April 5, 2017. 5. Testing for MH. Malignant Hyperthermia Association of the United States Web site. http:// www.mhaus.org/testing. Accessed April 5, 2017. 6. Denborough MA, Forster JFA, Hudson MC, Carter NG, Zapf P. Biochemical changes in malignant hyperpyrexia. Lancet. 1970;295(7657):11371138. doi: 10.1016/S0140-6736(70)91214-6. 7. FAQs: dantrolene. Malignant Hyperthermia As-

sociation of the United States Web site. http:// www.mhaus.org/faqs/dantrolene. Accessed April 5, 2017. 8. Managing an MH crisis. Malignant Hyperthermia Association of the United States Web site. http://www.mhaus.org/healthcare-professionals/ managing-a-crisis. Accessed April 5, 2017. 9. Chavez LO, Leon M, Einav S, Varon J. Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Crit Care. 2016;20(1):135. doi: 10.1186/s13054-016-1314-5. 10. Walter EJ, Carraretto M. The neurological and cognitive consequences of hyperthermia. Crit Care. 2016;20(1):199. doi: 10.1186/s13054-0161376-4. 11. Denholm BG. Using informatics to improve the care of patients susceptible to malignant hyperthermia. AORN J. 2016;103(4):365-376. e1-4. doi: 10.1016/j.aorn.2016.02.001. 12. Isaak RS, Stiegler MP. Review of crisis resource management (CRM) principles in the setting of intraoperative malignant hyperthermia. J Anesth. 2016;30(2):298-306. doi:10.1007/ s00540-015-2115-8. 13. The Association of periOperative Registered Nurses. Guidelines for Perioperative Practice. Denver, CO: AORN; 2015:555-556,559.

Clinical VignettE For CE567 Juan Martinez arrives at the OR for a laparoscopic cholecystectomy, and standard monitors are applied. His initial blood pressure is 133/74 mmHg, heart rate 95 beats/minute, and oxygen saturation 98% on room air. Juan is 5 feet 10 inches tall and weighs 195 pounds. He is given fentanyl (Actiq) 150 mcg IV, propofol (Diprivan) 200 IV, lidocaine (Xylocaine) 50 mg IV, and succinylcholine (Anectine) 180 mg IV as determined by his health history. After an uneventful induction and intubation with a No. 8 endotracheal tube, the patient is placed on oxygen at a 2-liter flow rate with desflurane (Suprane) inhalation agent at 6% concentration. The nurse notes an elevated heart rate of 120 beats/minute and blood pressure of 180/105 mmHg, but she assumes it is in response to intubation. The nurse anesthetist adjusts the ventilator settings for a tidal volume of 900 mL and a respiratory rate of 10 breaths/ minute. The end-tidal carbon dioxide (ETCO2) level reads 44 mmHg. She places an esophageal temperature probe and gets a core reading of 96.9 F (36.1 C). After several minutes, the patient’s vital signs are HR 144 beats/minute, BP 205/115 mmHg, ETCO2 55 mmHg, and temperature 98.2 F (36.8 C). Working with the nurse anesthetist, the RN troubleshoots the anesthesia circuit, increases the respiratory rate to blow off more carbon dioxide and draws a venous blood gas to send for evaluation. The nurse gives an additional 100 mcg of fentanyl IV with no decrease in the patient’s heart rate. Upon closer examination, Juan exhibits muscle contracture in his jaw, alarming the staff and alerting the team to the possibility of malignant hyperthermia.

32 | OR TODAY | SEPTEMBER 2018

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CE567

How to Earn Continuing Education Credit 1 What venous blood gas labs would

the clinician expect to find for Juan?

a. Hyperkalemia, hypercarbia with a PaCO2 > 60 mEq b. Hypokalemia, hypocarbia with a PaCO2 < 45 mEq c. Hyponatremia, pH > 7.45 d. Hyperkalemia, pH < 7.45

2 What is the first step the anesthesia

provider should take in caring for Juan?

a. Call for a stat chest X-ray b. Apply heating pads to the patient c. Stop all anesthetic agents and administer 100% oxygen d. Continue with the surgery

hich agent was a trigger for Juanâ&#x20AC;&#x2122;s 3 W malignant hyperthermia episode?

a. Propofol (Diprivan) b. Fentanyl (Actiq) c. Desflurane (Suprane) d. Lidocaine (Xylocaine)

hich test can definitively determine 4 W malignant hyperthermia in Juan?

a. DNA testing b. MRI c. CT scan d. Caffeine halothane contracture test

Clinical VignettE ANSWERS 1. Answer: A, High potassium results from the breakdown of muscle, and a rise in carbon dioxide of more than 60 mEq is the hallmark indicator of malignant hyperthermia. 2. Answer: C, Rapid, effective treatment of MH requires simultaneous actions by the perioperative nurses and physicians. An important step in the immediate treatment of suspected MH is for the anesthesiologist to stop the administration of triggering agents and flush the ventilator with 100% oxygen. 3. Answer: C, Inhalation agents, like desflurane (Suprane), can trigger episodes of malignant hyperthermia. 4. Answer: D, Caffeine halothane contracture test is the best test for definitive diagnosis of malignant hyperthermia in the patient. WWW.ORTODAY.COM

1. Read the Continuing Education article. 2. Go online to ce.nurse.com to take the test for $12. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at https://www.nurse.com/ sign-up for $49.95 per year.

Deadline Courses must be completed by 4/15/2019 3. If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer. 4. Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test. 5. All users must complete the evaluation process to complete course. You will be able to view a certificate on screen and print or save it for your records.

Accredited In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider #50-1489). OnCourse Learningâ&#x20AC;&#x2122;s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider #CEP16588.

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PROVEN PRACTICES PREVENT INFECTIONS BY D O N SA D L E R

Despite technological advances and a growing awareness of the problem, infections remain a serious issue in many hospital operating rooms today.

According to the Centers for Disease Control Prevention(CDC), between five and 10 percent of all hospital patients become infected with a healthcare associated infection (HAI) each year. Whatâ&#x20AC;&#x2122;s more, as many as one out of every 25 hospital patients has an HAI on any given day.

Even worse, up to 75,000 patients die from HAIs annually. And HAIs cost hospitals between $26 billion and $33 billion annually while lengthening patientsâ&#x20AC;&#x2122; hospital stays by between seven and 11 days, according to the CDC.

problems associated with infections Infections can lead to a wide range of patient problems. These include delayed recoveries, extended hospital stays, readmissions (including to the ICU), additional surgeries and, in the worst-case scenario, death.

For hospitals, infections can lead to increased costs, reduced or denied reimbursements, government penalties, patient lawsuits and a tarnished reputation. “OR staff are some of the most knowledgeable people about infections and the risk that patients face when undergoing a surgical procedure,” says Dr. Sarah Simmons, CIC, FAPIC, science director for Xenex. “But they may not always understand the relationship between environmental contamination and the patient acquiring an infection,” Simmons adds. Katherine Velez, PhD, scientist, Clorox Healthcare, says while most OR personnel are aware of the problem of infections, there are still awareness gaps around best practices for preventing infections and areas where current protocols are falling short. “For example, while experts agree that thorough cleaning and disinfection of environmental surfaces is a critical step in limiting the spread of pathogens, studies suggest that only about 30 to 50 percent of surfaces are adequately cleaned and disinfected,” says Velez. Velez believes that many factors contribute to gaps between best practice and actual practice. “These range from pressure to reduce room turnaround times to failure to follow manufacturer’s recommendations for use and use of disinfectants with inadequate antimicrobial activity,” she says. 3M Medical Affairs Director Victor Miranda says that awareness of the problem of infections varies among OR personnel when it comes to knowledge of infections within their own facility. “Sometimes that information is not shared with frontline staff, and sometimes it’s not even collected,” says Miranda. “Overall, there is a basic understanding of the problem of infections,” he adds. “But to be truly effective, clinicians have to understand the details of their technique. This comes with education, practice and real-time feedback on how they’re doing.”

article contributors

Dr. Sarah Simmons Science Director, Xenex

common types of infection According to Velez, surgical site infections (SSIs) account for approximately 23 percent of all HAIs. “The microorganism that most commonly causes SSIs is Staphylococcus aureus,” she says. “SSIs are obviously devastating for patients,” says Simmons. “But they can cost health care facilities more than $50,000 in additional patient care per infection.” CLABSI and CAUTI are also common infections in the OR, says Miranda. “The causes of SSIs are multi-factorial, but it all stems from bacterial contamination at the site of the surgical wound,” he says. The sources of contamination are varied. “But they start with the patients themselves, primarily their skin,” says Miranda. “Infections can also come from clinicians if they haven’t appropriately disinfected or don’t wear the right protective equipment.” Additionally, infections can come from the environment. “This includes the instruments and equipment used, as well as the beds and linens,” say Miranda. “Environmental contaminants can also be found in the water and the air.” Simmons says that a lot of attention is being paid to environmental contamination as a cause of infections due to new research showing that a significant amount of contamination remains in the OR even after it has been cleaned with traditional cleaning methods. “This research has established that the OR environment is far more contaminated than previously thought,” says Simmons. “This contamination is a cause of many infections.” For example, she notes that studies have shown that contamination builds in the OR during the day even when it is cleaned between procedures. “Staphylococcus aureus, Enterococcus spp., Klebsiella spp. and Pseudomonas spp. are capable of living on OR surfaces anywhere from a couple of hours to more than 30 months,” says Simmons.

Katherine Velez

Scientist, Clorox Healthcare

Victor Miranda

Director, 3M Medical Affairs

preventing patient infections

importance of environmental factors

According to Velez, up to 55 percent of SSIs could be prevented with current evidence-based practices designed to reduce the risk of infection.

Simmons believes the environment has long been underappreciated as a factor in SSIs.

The most recent CDC guidelines for the prevention of surgical site infections includes a number of evidencebased recommendations, including the following:

Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or non-antimicrobial) or an antiseptic agent on at least the night before the operative day.

Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines. It should be timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made.

3 4 5

Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL. Also, normothermia should be maintained in all patients.

“But this is changing given some of the exciting new studies that have been published,” she says. For example, she points to one study that determined that hospitals using pulsed xenon ultraviolet (UV) after terminal cleanings of the OR have seen dramatic reductions in SSI rates. In the study, a two-minute cycle of intense pulsed xenon UV light disinfection eliminated 72 percent more pathogens on high-touch OR surface areas than manual cleaning alone. “The authors noted that the short room turnover time is feasible even for a busy OR,” says Simmons. “Robots” make in-between case disinfection possible due to their instant-on capabilities, says Simmons. “In just 2 minutes, LightStrike robots are able to destroy microbial contamination on the OR and surgical instrument tables, as well as the anesthesia area at the patient’s head,” she says. Velez stresses the role of environment in infection prevention. “Establishing and maintaining thorough daily between-case and terminal cleaning and disinfecting procedures is a corvnerstone of any effective infection prevention and control program, she says." “Therefore, when selecting a surface disinfectant product, it’s important to consider factors such as relevant pathogen kill claims, contact times, easeof-use and safety,” Velez adds. Clorox Healthcare hydrogen peroxide cleaner disinfectants clean and disinfect in one step, says Velez. “Contact times on most bacteria and viruses are between 30 seconds and one minute. This cuts down the time it takes to effectively address blood and bodily fluids, she says.”

evidence-based practices are key

In the end, Velez believes that OR personnel can make the biggest difference in infection prevention by focusing on proper implementation of evidence-based practices like those listed above. “In addition, they should actively partner with other patient safety stakeholders such as infection preventionists, environmental services teams and patients themselves,” says Valez.“The best results are achieved by creating a culture where patient safety is everyone’s responsibility.”

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SPOTLIGHT ON:

Sarah Wolf

, BSN

BY MATT SKOUFALOS

egaled with tales of nursing by her grandmother, who worked at Columbia Presbyterian Hospital, Massachusetts native Sarah Wolf was headed for a career in medicine as early as high school.

In college, Wolf concentrated on women’s health issues until her final undergraduate year, when she took on rotations in a 12-bed pediatric intensive care unit (PICU) at New York University Medical Center. Exposed to the acute nature of the PICU setting, she realized the intersection of technology and pediatric critical care more closely matched her interests. “Medicine and the human body was something that I was always interested in,” Wolf said. “That kind of science was what I was always drawn to. It seemed a natural fit for my personality. I decided I would rather do that upon graduation rather than women’s health.” Amid the intensity of the work, Wolf also found her emotional limits tested frequently. In the beginning, she remembers “a lot of tears and taking a lot of the work home with me emotionally,” but she kept up the assignment for about five years. “We were all young, we were all night shift, and we were able to support each other through that,” she said. “I would have patients who were chronically ill for years, and would then pass away, or a

42 | OR TODAY | SEPTEMBER 2018

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kid who was in a motor vehicle accident who’s paralyzed from the neck down. It was trying.” In addition to the emotional fatigue, Wolf also acknowledged the task-oriented nature of the work, a tangle of keeping up with “so many medications, treatments, machines, and monitors” in which the delivery of care can sometimes be lost. “You’re there not to work a shift, but to take care of a child,” Wolf said. “A lot of my patients were originally in the neonatal ICU, born prematurely, and have chronic lung disease. Most of them end up weaning off the ventilator and having the tracheostomy removed. That’s the best. But there is a population that just will never come off the support.” Today, Wolf is a case manager in the progressive care unit at Children’s Hospital of Philadelphia (CHOP). Relying on her PICU experience, she specializes in preparing families to take technology-dependent children home from the hospital. Although her current assignment requires a depth of social work and planning skills, Wolf leans on a highly technical nursing background in guiding home-based care for vulnerable patients and their families. That assignment, which involves visiting with families who face significant health and income disparities in

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“To see what people go through every day – a lot of poverty, a lot of underserved populations – I was able to see what the difficulties were in the home.” the Philadelphia area, was “eye-opening” from the beginning, she said. “It’s primarily Medicaid patients living in difficult situations with children who ware medically fragile,” Wolf said. “Some families were extremely appreciative to have someone coming and talking to them, and some families were busy and didn’t want me to come in for that long.” “To see what people go through every day – a lot of poverty, a lot of underserved populations – I was able to see what the difficulties were in the home,” she said. “We do a lot of validating and speaking back [to parents]; they know we’re understanding them, and they’re being heard.” Wolf’s job is complicated by a number of factors, many of them institutional. Reimbursement rates for the services she delivers are dwindling, a result of Medicaid and insurance cutbacks, while physicians insist that the patients they’re discharging receive a quality of care at home comparable to that which they get in the hospital setting. Patients are released with 24-hour at-home nursing care for the first two weeks after discharge; that decreases to 16 hours a day, which makes staffing a challenge. Lesser rates of pay for home care versus hospital shifts also affects the work, as does the challenge of finding approvals for high-tech care. “It’s getting difficult to find home care nurses to take care of technology-dependent kids, and the kids we’re sending home are sicker than they were five years ago,”

Wolf said. “Every year, my manager is hiring more people because there’s so much need to maneuver what is needed, how this patient can access it, and who’s going to pay for it. We have to get pretty creative. There’s a monthly meeting to discuss those patients [denied reimbursement] to see if there’s anything that can be done to facilitate their discharge, or facilitate to a lower level of care if they’re medically stable.” Wolf’s assignment is an evolving one, and it becomes increasingly difficult year after year, she said. Wolf has found her interest in public health issues deepening as her expertise in technology-dependent discharges continues to expand. She believes that a master’s in public health might be on her horizon, as she considers a shift into policy work as a long-term goal. For now, Wolf continues to support her patients and coworkers as they deliver a high quality of care in a mentally demanding environment. “Having two kids myself now, I don’t think I could go back to PICU nursing,” Wolf said. “We see sick children from all over; we see things that people in medicine will have never seen. No matter how small the intervention we’re doing, it’s a big deal to parents because it’s their child. All of it is scary.” “Families are sometimes in my unit for a year or more, and they have a lot of emotional problems that they need support with,” she said. “When it seems like they’re heading home, it’s still a long road ahead, even though the kids are doing better medically than when they were in the ICU.”

SEPTEMBER 2018 | OR TODAY |

OUT OF THE OR fitness

Greek Island Report: Find Your Path to ‘Ef-zeen’ By Marilynn preston

year ago, “All Is Well” was officially launched at a beach bar on a small Greek island that is part legend, part movie set and all olive oil, all the time. As some dear readers know, “AIW” is a 200-page book, weighing less than a pound, with absolutely no dieting at all! The book’s full name is “All Is Well: The Art {and Science} of Personal Well-Being” and it’s a summing-up of many things I’ve learned as a journalist in the 40plus years I’ve been writing about health and happiness, fitness and wellness, standing desks and sitting presidents. Last year, “All Is Well” made her first visit to Greece, birthplace of moderation in all realms. (Thankfully, this includes French fries.) More than 100 well-wishers showed up for a party celebrating her coming in to harbor, and people from 12 different countries took her home. It turns out that the Greeks have a classic expression for that felt sense of personal well-being. The actual spelling would require ancient Greek – but in English, it sounds like “ef-zeen.” “Ef-zeen!” Say it with gusto. The

44 | OR TODAY | SEPTEMBER 2018

good life. Life in balance. A life of serenity, security, love, happiness ... “How do you know you’re on the right path?” a woman asked me at a book event in Sarasota. It’s a question that comes up a lot. “It’s like throwing up,” I like to respond. “You know when it’s happening.” “Ef-zeen!” It’s simple to say – but not all that easy to maintain, which is why we’re grateful to be back in Greece for a refresher course. So far it involves serious amounts of sunshine, reading and a deep dive into the restorative nature of long walks, energizing swims and making hummus from scratch. As a self-indulgent happy-anniversary-to-us, here are three themes in the book that bear repeating, because personal well-being is very much under attack these days. That means it’s more important than ever to increase awareness, be vigilant and get as much movement and joy into your day as you possibly can.

BE YOUR OWN UNCLE SAM I can talk about this until I’m red, white and blue in the face: You can’t depend on the government to protect your health and promote your well-being. Self-care is the best care, aided by the best East-West

health care team you can assemble. “The U.S. government is doing a pathetic job of keeping us safe from harmful foods and pesticides, toxic cosmetics and chemicals, polluted air and yucky water,” I trumpeted when the book first came out. And 500 days into our current regime, policies that work against public health and personal well-being are even more prevalent, even more disturbing.

OUTSMART YOUR SMARTPHONE The theme of “too much technology” couldn’t be timelier, and the solution couldn’t be more elusive. We are tethered to addictive devices that appear to make our lives easier (“Alexa! What time is it?”), but in fact our lives feel more hectic, more distracted and more demanding. For sure, it’s taking a toll on our health, as many kinds of cancers grow and suicide rates rise. But the stress of too much technology always bounces back to personal choice: Will you outsmart your smartphone by using it selectively? Will you leave it behind in pursuit of a day, a night, that just unfolds? Will you spend less time checking your feed and more time feeding your mind and body’s need

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When Quality Matters

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OUT OF THE OR health

Enjoy Summer Potlucks the Healthy Way By Lauren Swann, M.S., R.D., L.D.N. ummer is the wonderful season of backyard barbecues, shoreside picnics and family feasts. And while good fun and good eating is plentiful, all those gatherings can start to take a toll on your diet – especially if you’re trying to watch what you eat. So how do you enjoy yourself without eating something you’ll regret? Read on for healthy potluck pointers.

1. Plan ahead. Contributing a dish that suits your meal plan lets you assume control over your potluck choices. Bring grilled vegetables or a healthy pasta salad, for instance, and you’ll be guaranteed to have at least one healthful option. If you eat a vegetarian or gluten-free diet, bring a hearty dish that meets your needs.

tions than usual because you’ll likely eat more dishes than at a normal meal.

3. Start with veggies. If there are snacks or appetizers available before the main meal, go for the vegetable platter. Nibbling on vegetables before the meal can help remind you of your healthy commitments and can help curb your hunger before the meal is served.

4. Watch the carbs. Be reasonable about corn on the cob, potato salad, pasta salad, sweets and caloric beverages. A little of all of these can really add up! To make sure you serve yourself a balanced meal, try to fill half your plate with vegetables, a quarter with carb-based dishes and a quarter with lean protein.

5. Choose lean meats. Skinless chicken breast, fish, pork loin or a lean turkey or beef burger is a good bet.

8. Avoid nonstop noshing. At some events, food may be available for hours and it might be possible to snack all day. If you think this will be the case, go in with a plan. For example, decide you’ll have one appetizer, eat during the main meal and then avoid snacking afterward.

9. Eat safely. Make sure hot foods stay hot (above 140 degrees F) and cold foods stay cold (below 40 degrees F). Avoid perishable foods that have been sitting out for more than two hours. And cover dishes and snacks to keep insects at bay.

10. Focus on fun.

7. Be discerning about desserts.

Summer gatherings celebrate the longest and brightest days of the year, so take time to enjoy the sun’s rays, long evenings and awesome sunsets with family and friends. Potlucks are as much about sharing stories and fun as they are about food, so focus less on feeding at the table and more on feeding your soul.

Potlucks can be full of tempting treats, but they can also provide simple plea-

– DiabeticLivingOnline.com

2. Keep an eye on portions.

6. Drink plenty of water.

It’s far too easy at a potluck to overfill your plate, even when you just take a little of everything. A quick survey of the buffet table can help you pinpoint which dishes you really want on your plate and the ones you can pass on. When serving, spoon up smaller por-

Staying well hydrated can help you feel full. Opt for water or sparkling water over sweetened beverages if you can.

46 | OR TODAY | SEPTEMBER 2018

sures. Consider skipping the cakes and cookies to focus on seasonal fruit. Freshly picked melon, peaches and berries at their peak can all be a delightful and memorable treat.

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SEPTEMBER 2018 | OR TODAY |

OUT OF THE OR nutrition

The Power

of Protein at Breakfast By UNIVERSITY OF EASTERN FINLAND oast, bagels, oatmeal and cold cereal. That’s the highcarb stuff of the typical American breakfast. Yet the latest research shows that including more protein at the morning meal might provide many health benefits, including weight loss and preserving muscle tissue.

More protein, better breakfast Higher-protein breakfasts have been studied in teenagers and young adults and found to reduce subsequent hunger and calorie intake, and prevent gains in body fat. In another study, postmenopausal women getting 1.2 grams (g) per kilogram (kg) of protein a day experienced what the authors called “profound effects on metabolic function,” including 45 percent less muscle loss – a common side effect of low-calorie diets. A third study found that 15 g of supplemental protein at breakfast and lunch resulted in improved muscle strength and physical function of a group of older adults. Combining higher-protein meals with physical activity may offer even more protection against loss of muscle mass.

How much is enough For adults, the current Recommended Dietary Allowance (RDA) for protein is 0.8 g per kg of body weight, which comes out to 55 g a day for a person weighing 150 pounds (68 kg). But several researchers have come to the conclusion that getting more protein (up to 1.2 g per kg) throughout the day, especially for older adults, and making breakfast a

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protein-rich meal, can have impressive health benefits. Going with the 1.2 g/kg recommendation, that would be 82 g of protein a day for the same 150-pound person, which divided evenly over your day would be about 27 g per meal. While we each have our own unique nutrient requirements, it’s a worthwhile goal to increase your protein intake at breakfast.

Get a protein punch in the morning An even distribution of protein throughout the day creates a much higher protein breakfast than most people consume. In fact, our breakfasts tend to have the lowest protein content overall, with lunch slightly more, and dinner with the highest protein content of all. For example, a breakfast consisting of a bowl of instant oatmeal, 1/4 cup blueberries, and coffee with a splash of milk provides only seven grams of protein. So, power up your breakfast with more protein-rich options, including lean proteins (eggs, tofu, turkey), dairy products (milk, cottage cheese, cheese and yogurt), soymilk, nuts and seeds (pistachios, almonds, hemp seeds), and nut and seed butters (peanut or almond butter). – Environmental Nutrition

SEPTEMBER 2018 | OR TODAY |

OUT OF THE OR

Recipe

recipe

the

52 | OR TODAY | SEPTEMBER 2018

Nectarine Betty

INGREDIENTS:

For the betty: • 6 ripe, but still a bit firm, nectarines, cut in slices (5 to 6 cups) • 3 tablespoons lemon juice • 2 teaspoons grated lemon zest • 1 1/2 cups graham cracker crumbs • 4 tablespoons butter, melted • 1/4 cup sugar • 1 cup brown sugar • 1/2 teaspoon cinnamon • 1/4 teaspoon ginger • 1/4 teaspoon nutmeg • Pinch of cloves • 1/8 teaspoon salt For the topping: • 1/2 cup (110 g) brown sugar • 3 teaspoons butter To serve (optional): • French vanilla ice cream or whipped cream

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

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OUT OF THE OR recipe

A Simple Dessert

Courtesy of the Brass Sisters I

recently had the pleasure of meeting Marilynn and Sheila Brass (the Brass sisters) at a James Beard Award dinner and, frankly, I was smitten. They are so enthusiastic and interesting to chat with that I couldn’t wait to check out their television show, “The Food Flirts,” on PBS. (Check your local listing.) In addition to their show, the Brass sisters have penned a number of cookbooks that have the same theme in common: heirloom recipes rediscovered. They have spent a lifetime collecting used cookbooks, original hand-written recipe books and loose handwritten recipes. In “Heirloom Baking with the Brass Sisters” (Black Dog & Leventhal, 2011), they have selected 150 recipes that they carefully tested and updated. I selected this summertime Seriously Simple-style dessert. As a traditional American dessert, betties are even easier to put together than their culinary cous-

ins: cobblers, buckles and crumbles. In this recipe the betty uses buttered, spiced graham cracker crumbs instead of the traditional buttered cubes of bread or breadcrumbs. And to gild the lily, the authors have further enhanced this classic with a crispy topping of brown sugar and butter. I love this summer rendition using nectarines (I love the white ones) instead of apples. Enjoy this after a barbecue or simple grilled dinner. Don’t forget the French vanilla ice cream to serve alongside. The Brass sisters have shared some sweet tips for you as well: • A betty is different from a crisp because of the layer of crumbs on the bottom. Don’t be surprised if these bottom crumbs are a little juicy; the fruit just melts into them. • Sometimes the betty falls in a bit if it sits around waiting to be served, but don’t fret; the dessert loses

Nectarine Betty Makes 9 generous servings 1.

2. 3.

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Set the oven rack in the middle position. Preheat the oven to 375 F. Coat a 9-by9- inch baking pan with vegetable spray. Line a 14-by-6-inch baking sheet with foil. To make the betty: Place nectarines in a large bowl and sprinkle with lemon juice. Place lemon zest and graham cracker crumbs in another bowl. Add butter, and mix thoroughly with your hands (wear disposable gloves if desired) until texture is sandy. Add sugar, brown sugar, cinnamon, ginger, nutmeg, cloves and salt, and mix in. To add the topping: Layer half of crumbs on bottom of pan. Layer sliced nectarines on top of crumbs. Sprinkle remaining crumbs over fruit. Distribute brown sugar evenly over crumb topping, and dot with butter. Place pan on baking sheet in oven. Bake 30 to 35 minutes, or until topping is browned. If topping appears to be browning too quickly, cover loosely with foil. Let cool on a rack until pleasantly warm. Serve warm with whipped cream or vanilla ice cream. Store covered with wax paper in the refrigerator. Leftovers may be reheated in 300-degree F oven for 10 minutes.

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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!

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Tips to Keep Family Motivated and Moving According to the U.S. Department of Health and Human Services (HHS), there are many good reasons for families to stay active, and regular physical activity is something that everyone can do, despite one’s age or body type. Many parents know the importance of being physically active, but they don’t always know where to start when it comes to motivating their family to live such a healthy lifestyle. The good news is that it’s not as difficult as it may seem, and a little bit of motivation goes a long way. “Most parents are very busy today with work and all the obligations that come with just getting by each day,” explains Sarah Walls, personal trainer and owner of SAPT Strength & Performance Training, Inc. “Family fitness is also something that gets pushed aside when schedules

56 | OR TODAY | SEPTEMBER 2018

are busy, yet it’s one of the most important things they can do to care for their family. We have to make it a high priority and way of life.” Here are some tips to help keep families motivated to be physically active: •S tart with small goals and add more to it as you go along. •H old a family meeting about how you want the family to be more physically active. Discuss why it’s important to be active and what the benefits are. •C hoose some activities. Try to vary the ways that your family will be active together. Not everyone likes the same type of activity, so if you mix it up you will keep everyone interested and more motivated to participate. • I t’s important that the family know that being physically active is

going to be part of your family’s lifestyle. It’s not something that will be gone in a week or month. • The most effective way for parents to motivate and teach their children to live a physically active lifestyle is to lead by example. Parents who are physically active demonstrate to their children the importance of being active, even without saying anything else to motivate them.

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The News and Photos that Caught Our Eye This Month

OUT OF THE OR pinboard

Ex-Nun: ‘Always Eat Dessert’ When it comes to weight-loss, advice from a former nun may be heaven sent. Especially if that former nun is Mary Lou Reid, who entered the convent as a heavyset, shy 18-year-old and left five years later a confident, svelte woman 50 pounds lighter. Even today, Reid continues to follow the convent lifestyle that led her to maintain her weight for 50 years. In her new book, “Always Eat Dessert,” published by Post Hill Press, Reid shares the Seven Holy Habits she discovered in the convent that can help anyone live a healthier lifestyle. They are: Holy Habit No. 1: See Yourself as Thin Until You Actually Are (Visualization) Holy Habit No. 2: Always Eat Dessert Holy Habit No. 3: Don’t Count Calories but Calories Count Holy Habit No. 4: Being a Couch Potato is OK Holy Habit No. 5: Don’t Be on a Diet in a Restaurant Holy Habit No. 6: Opt Out of Diet Food Holy Habit No. 7: Always Take Time for Yourself “You don’t have to enter a convent to follow these principles. The Convent Diet really isn’t a diet at all. It is a way of looking at food and at life. Food becomes a friend instead of an enemy. The Convent Diet is neither trendy nor a magic bullet, and for most, it takes some trial and error, but it works,” Reid says.

Survey: Parents Want Summer to End After Just 13 Days School is out for the summer, which means that parents have the enormous challenge of coming up with a daily regimen of activities that educate and entertain their children. And while most say they’re up to the task, adding the responsibility of social activities director along with being a mom or dad can come with a price. Groupon asked 2,000 parents about their summer plans, and found that they’re ready for summer break to end after just 13 days. More than half (58 percent) of parents say they get stressed out trying to keep their children busy over break, and 75 percent are ready for their kids to go back to school at the end of the summer. “It’s summertime and you gotta find your kids something to do. Because an energetic kid with too much free time can land you in small claims court,” said actress and Groupon spokesperson Tiffany Haddish in the company’s new summer radio ad. The survey – conducted by OnePoll and commissioned by Groupon – identified other top causes of summer stress and found that letting the kids stay in the house rather than going outside to play, lacking awareness of where to find affordable children’s activities in their community, worrying about the impact of rising gas prices and letting their children spend too much time in front of their electronic devices all contributed to parents’ current state of unease. While most parents are anxious about finding enough things for their kids to do, they shared some top ways to help you totally win summer and make this break one to remember for the whole family. According to the research, the best ways to keep your children occupied include taking them to a local amusement or water park, a movie, the zoo, bowling or camping. For those families looking to have the perfect time this summer on just about any budget, Groupon offers a number of top activities in your local community, including deals on family activities, tickets and events, outdoor fun and top deals of the week.

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SEPTEMBER 2018 | OR TODAY |

INDEX

advertisers

Alphabetical Advance Medical Designs, Inc.…………………………41 AIV Inc.……………………………………………………………… 45 Alco Sales Service, Co.…………………………………… 54 C Change Surgical………………………………………………15 Case Medical, Inc.…………………………………………… 50 Cygnus Medical…………………………………………………… 9 D. A. Surgical……………………………………………………IBC Doctors Depot………………………………………………… 40 AORN of Middle Tennessee…………………………… 48

Encompass Group…………………………………………… 45 GelPro……………………………………………………………………13 Healthmark Industries Company, Inc.…………… 4 Innovative Medical Products………………………… BC Innovative Research Labs……………………………… 55 Jet Medical Electronics Inc…………………………… 54 Key Surgical……………………………………………………… 20 MD Technologies inc.……………………………………… 49 Microsystems…………………………………………………… 47

Mobile Instrument Service & Repair……………… 6 Nozin…………………………………………………………………… 25 oneSOURCE Document Site……………………… 16-17 Pacific Medical………………………………………………… 49 Palmero Health Care…………………………………………19 Paragon Services……………………………………………… 34 Ruhof Corporation……………………………………………2, 3 TBJ Incorporated………………………………………………… 5 USOC Medical…………………………………………………… 35

ANESTHESIA

GENERAL

Doctors Depot………………………………………………… 40 Innovative Research Labs……………………………… 55 Paragon Services……………………………………………… 34

AIV Inc.……………………………………………………………… 45

Cygnus Medical…………………………………………………… 9 D. A. Surgical…………………………………………………… 59 Innovative Medical Products………………………… BC

categorical

ASSET MANAGEMENT Microsystems…………………………………………………… 47

HOSPITAL BEDS/PARTS Alco Sales Service, Co.…………………………………… 54

INFECTION CONTROL/PREVENTION

REPAIR SERVICES Cygnus Medical…………………………………………………… 9 Doctors Depot………………………………………………… 40 Jet Medical Electronics Inc…………………………… 54 Mobile Instrument Service & Repair……………… 6 Pacific Medical………………………………………………… 49 USOC Medical…………………………………………………… 35

C Change Surgical………………………………………………15 Jet Medical Electronics Inc…………………………… 54

Advance Medical Designs, Inc.…………………………41 Alco Sales Service, Co.…………………………………… 54 Cygnus Medical…………………………………………………… 9 Encompass Group…………………………………………… 45 Healthmark Industries Company, Inc.…………… 4 Nozin…………………………………………………………………… 25 Palmero Health Care…………………………………………19 Ruhof Corporation……………………………………………2, 3 TBJ Incorporated………………………………………………… 5

CARTS/CABINETS

INSTRUMENT STORAGE/TRANSPORT

Alco Sales Service, Co.…………………………………… 54 Case Medical, Inc.…………………………………………… 50 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…………… 4 Innovative Research Labs……………………………… 55 TBJ Incorporated………………………………………………… 5

Case Medical, Inc.…………………………………………… 50 Cygnus Medical…………………………………………………… 9 Key Surgical……………………………………………………… 20

GelPro……………………………………………………………………13 Healthmark Industries Company, Inc.…………… 4 Key Surgical……………………………………………………… 20

INSTRUMENT TRACKING

SINKS

ASSOCIATION AORN of Middle Tennessee…………………………… 48

BIOMEDICAL oneSOURCE Document Site……………………… 16-17

CARDIAC PRODUCTS

CRITICAL CARE Innovative Research Labs……………………………… 55

CS/SPD Case Medical, Inc.…………………………………………… 50 MD Technologies inc.……………………………………… 49 Microsystems…………………………………………………… 47

DISINFECTION Case Medical, Inc.…………………………………………… 50 Cygnus Medical…………………………………………………… 9 Palmero Health Care…………………………………………19 Ruhof Corporation……………………………………………2, 3

DISPOSABLES

Case Medical, Inc.…………………………………………… 50 Microsystems…………………………………………………… 47

INVENTORY CONTROL Key Surgical……………………………………………………… 20

MONITORS Doctors Depot………………………………………………… 40 Pacific Medical………………………………………………… 49 USOC Medical…………………………………………………… 35

ONLINE RESOURCE oneSOURCE Document Site……………………… 16-17

OR TABLES/BOOMS/ACCESSORIES D. A. Surgical…………………………………………………… 59 Innovative Medical Products………………………… 60

Alco Sales Service, Co.…………………………………… 54

OTHER

ENDOSCOPY

AIV Inc.……………………………………………………………… 45

Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…………… 4 MD Technologies inc.……………………………………… 49 Mobile Instrument Service & Repair……………… 6 Ruhof Corporation……………………………………………2, 3

PATIENT MONITORING

FALL PREVENTION

PATIENT WARMING

Alco Sales Service, Co.…………………………………… 54 Encompass Group…………………………………………… 45

Encompass Group…………………………………………… 45

AIV Inc.……………………………………………………………… Jet Medical Electronics Inc…………………………… Pacific Medical………………………………………………… USOC Medical……………………………………………………

45 54 49 35

POSITIONING PRODUCTS

REPROCESSING STATIONS TBJ Incorporated………………………………………………… 5

RESPIRATORY Innovative Research Labs……………………………… 55

SAFETY

TBJ Incorporated………………………………………………… 5

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

SURGICAL MD Technologies inc.……………………………………… 49

SURGICAL INSTRUMENT/ACCESSORIES C Change Surgical………………………………………………15 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…………… 4 Key Surgical……………………………………………………… 20

TELEMETRY AIV Inc.……………………………………………………………… 45 Pacific Medical………………………………………………… 49 USOC Medical…………………………………………………… 35

TEMPERATURE MANAGEMENT C Change Surgical………………………………………………15 Encompass Group…………………………………………… 45

WASTE MANAGEMENT Advance Medical Designs, Inc.…………………………41 MD Technologies inc.……………………………………… 49 TBJ Incorporated………………………………………………… 5

Advance Medical Designs, Inc.…………………………41

58 | OR TODAY | SEPTEMBER 2018

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