OR Today - November 2018 by MD Publishing

COMPANY SHOWCASE MEDLINE

CE ARTICLE FLUID MANAGEMENT

CORPORATE PROFILE

SPOTLIGHT ON JACKIE PATTERSON

NOVEMBER 2018

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OR TODAY | November 2018

contents features

BURNOUT AND BULLYING

Among perioperative nurses, burnout and bullying are sometimes referred to as the “killer B’s.” They can result in added stress, job frustration and sleepless nights for many OR nurses. It's critical that health care organizations do everything they can to reduce instances of bullying in order to help reduce levels of burnout among OR nurses.

Medline Industries provides the necessary components to implement an evidence-based, preoperative decolonization protocol. These products represent a convenient, yet multifaceted, approach to preoperative decolonization in an effort to help prevent SSIs.

Understanding fluid balance and related fluid management leads to positive patient outcomes. To foster positive patient outcomes, perioperative nurses must understand fluid balance and fluid management in the surgical patient. The nurse must recognize fluid volume deficit and implement evidence-based practices to maintain patient homeostasis and safety.

After 35 years of providing world-class patient positioning solutions to surgical teams, Innovative Medical Products Inc. stands primed for a new era of growth and forward focus that will ultimately bring enhanced benefits to customers. Thanks to the acceptance of doctors, nurses, hospitals and surgical centers, Innovative Medical Products has been experiencing a period of sustained growth.

COMPANY SHOWCASE

CE ARTICLE

CORPORATE PROFILE

OR Today (Vol. 18, Issue #11) November 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. © 2018

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contents features

PUBLISHER John M. Krieg

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VICE PRESIDENT Kristin Leavoy

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SPOTLIGHT ON

EDITOR John Wallace

Jackie Patterson, BSN, CCRN, FNE-SA

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ART DEPARTMENT Jonathan Riley Karlee Gower Kathryn Keur

ACCOUNT EXECUTIVES Jayme McKelvey Megan Cabot Nick Whitehead Jeffrey Berman

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DIGITAL SERVICES

win lunch for your department!

Roast Herbed Chicken with Caramelized Garlic, Dates, Lemon and Olives

OR TODAY CONTEST

RECIPE OF THE MONTH

Travis Saylor Cindy Galindo Kennedy Krieg

CIRCULATION Lisa Cover Melissa Brand

WEBINARS Linda Hasluem

INDUSTRY INSIGHTS 10 News & Notes 18 Webinar Recap

ACCOUNTING Diane Costea

IN THE OR

23 Market Analysis 24 Product Focus: UV Disinfection 28 CE Article: Balancing Act: Managing Fluid Intake and Output in the Surgical Patient

OUT OF THE OR 50 Spotlight On 52 Fitness 54 Health 56 Nutrition 58 Recipe 60 Pinboard 62 Index

8 | OR TODAY | NOVEMBER 2018

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INDUSTRY INSIGHTS

news & notes

Fine Mesh Basket with Snap-Closure Healthmark Industries has announced the addition of the Fine Mesh Basket with Snap-Closure to its ProTech product line. Manufactured from stainless steel, the Fine Mesh Basket with Snap-Closure is 105 x 70 x 25 mm and ideal for safely washing small items that often get lost in instrument washers. The small perforations ensure effective water penetration during reprocessing. Simply place items in basket, close lid of basket and place into instrument washer for cleaning. The Fine Mesh Basket with Snap-Closure is available for individual purchase. • For more information, visit www.hmark.com.

Baxter Announces FDA Clearance of Actifuse Flow Baxter International Inc. announced U.S. Food and Drug Administration (FDA) clearance of Actifuse Flow Bone Graft Substitute for use in a variety of orthopedic surgical procedures. As the newest addition to Baxter’s growing osteobiologics surgery portfolio, Actifuse Flow offers accelerated bone growth in a new, easy-to-use, prepackaged delivery syringe for precise placement into small bony voids or gaps in the skeletal system. Actifuse Flow utilizes the proprietary silicate-substituted technology of Baxter’s Actifuse Bone Graft Substitute, which enhances silicon levels to accelerate bone formation. Actifuse Flow comes ready to use with no mixing or preparation involved and maintains its flowable consistency throughout surgery. The bone graft substitute is delivered directly from a preloaded syringe with the ability to start and stop delivery, making

10 | OR TODAY | NOVEMBER 2018

it compatible with open and less invasive surgical techniques and well-suited for filling small bone defects and complex geometries. As the graft substitute resorbs, it is replaced by the patient’s own bone during the body’s healing process. Baxter expects Actifuse Flow to be used in a variety of orthopedic surgeries in the pelvis, extremities and posterolateral spine. Actifuse Flow is the latest addition to Baxter’s osteobiologics surgery portfolio, which also includes Actifuse ABX, Actifuse Shape, Actifuse MIS and Altapore. These products are based on a proprietary silicate-substituted technology designed to accelerate bone growth and come in varying configurations to accommodate different surgical needs. Baxter expects Actifuse Flow to be available to U.S. customers by year-end. •

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INDUSTRY INSIGHTS

news & notes

Arjo Unveils IndiGo Technology for Medical Bed Transport Arjo has unveiled the IndiGo intuitive drive assist, designed to reduce ergonomic risk, support user safety, and improve the ease and efficiency of transporting patients on medical beds. IndiGo is the intuitive drive assistance that makes lighter transport available to any caregiver with just a touch – for safety and simplicity. Comprised of a powered fifth wheel installed beneath the bed, IndiGo is unlike other power drive systems, which are typically separate, bulky pieces of equipment. Once installed, IndiGo is always ready for use, saving time and effort to

store or transfer external equipment. “We put ourselves in the customers’ shoes and tried to imagine what their dream product would be like. We realized that to truly make a difference in terms of convenience, efficiency, safety and ease of use, we would have to come up with a completely new product concept. This led us to the idea of an integrated power assist that responds directly to user input, which became the basis for the IndiGo concept,” said Peter Lambord, senior product specialist, medical beds, Arjo. IndiGo eliminates the complexity of

additional equipment or controls. Users activate IndiGo by lifting the brake pedal with their foot. Then, as they push the bed, IndiGo assists with automatic slope detection, providing additional power when moving up slopes and braking assistance when moving down slopes. The user interface is intuitive enough to enable small positioning adjustments and sideways movements, and it requires minimal training to operate. IndiGo is available for Arjo’s Enterprise medical beds and Citadel patient care system and can be retrofitted to select Citadel and Enterprise beds. •

Filtration Group Stimulates Technological Advancements Filtration Group announced its third major acquisition in Buffalo Niagara. Executives from Filtration Group and acquired companies Buffalo Filter, Multisorb Technologies and Air System Products unveiled emerging technologies and active plans for employee recruitment. Following the announcement of the recent acquisition of Multisorb Technologies and the earlier additions of Air System Products and Buffalo Filter, Filtration Group has further expanded its portfolio in life sciences, health care, medical and an array of industrial markets. Filtration Group now has more than 7,200 employees across 28 countries and an annual revenue of more than $1.3 billion.

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The products being designed, engineered and manufactured by the three Buffalo-based companies are broadening Filtration Group’s capabilities to serve its customers with an unmatched depth of expertise in diverse market segments. “Buffalo Filter is designing medical devices to improve surgical safety, which has prompted national legislation for smokefree health care facilities,” said Samantha Bonano, president and CEO of Buffalo Filter. “As a part of Filtration Group, we are able to reach new markets and channels with some of the most comprehensive and advanced product lines in the world.” •

NOVEMBER 2018 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

Data Shows Leaf Healthcare Technology Reduces Pressure Ulcers Leaf Healthcare, maker of patient monitoring technology, announced that its wireless patient-wearable has been used to track the mobility of more than 20,000 patients for more than 1.8 million hours and has helped health care facilities reduce the number of hospital-acquired pressure ulcers by an average of 74 percent. The Leaf System has been deployed in health care facilities across the United States since 2014. Approximately 65 percent of deployments have been in critical care settings; 30 percent have been med-surg and the rest have been in telemetry units or long-term care settings. “Clinicians quickly recognize the benefits provided by the Leaf System,” said Barrett Larson, Leaf CEO and cofounder. “Adoption of Leaf leads to immediate, significant, and sustained reductions in rates of hospital-acquired pressure injuries. Leaf has been shown to be highly effective in both real-world clinical environments and rigorous research settings. Leaf is a safer, smarter solution to pressure injury prevention.” The Leaf System is the first FDA-cleared medical technology that continuously monitors the activity and position of patients to help identify those that could benefit from repositioning. Studies have shown that patients protected by Leaf are much less likely to develop pressure injuries. The Leaf System tracks patient movement and activity in bed-bound, chair-bound and ambulatory patients. Several studies have shown the Leaf System improves patient turning and mobility, reduces pressure injury rates, helps nurses prioritize patient care, improves unit workflow and saves hospitals non-reimbursed costs associated with the treatment of pressure injuries, as well as rental bed costs. •

12 | OR TODAY | NOVEMBER 2018

Hospital Reports Fewer Infections After Adding UV Disinfection Patient safety is a top priority at Rush Foundation Hospital, which was the first hospital in East Mississippi and West Alabama to deploy Xenex LightStrike Germ-Zapping Robots to enhance environmental cleanliness by disinfecting and destroying hard-to-kill germs, bacteria and superbugs in hard-to-clean places. The hospital announced that it has seen a 59 percent reduction in Clostridium difficile (C.diff) infection rates and a 100 percent reduction in Methicillinresistant Staphylococcus aureus (MRSA) infection rates since acquiring two LightStrike Germ-Zapping Robots one year ago. Rush’s two robots, Rossie and Zach, are utilized by the hospital’s Environmental Services team to disinfect rooms after a patient is discharged. Using high intensity pulsed xenon ultraviolet (UV) light, the robots quickly destroy microscopic pathogens that can cause infections. “Every time someone comes in to this facility they are bringing in contamination from the outside. Adding the LightStrike Germ-Zapping Robots to our thorough cleaning protocol is an additional measure we took to enhance patient safety and we are very excited about the success we’ve achieved. Our environmental services and infection prevention teams worked closely with Xenex to develop a plan to best utilize our robots and it’s very clearly working,” said Jason Payne, administrator of Rush Foundation Hospital. “We made this investment as a commitment to the wonderful community we serve, and we are extremely pleased with the results we have achieved.” •

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Long Beach Facilities Remain CNOR® Strong MemorialCare’s Long Beach Medical Center and Miller Children’s & Women’s Hospital Long Beach have earned the CNOR® Strong designation from the Competency & Credentialing Institute (CCI) for the third consecutive year. The CNOR® Strong designation is given to hospitals and medical centers having at least 50 percent of its operating room nursing staff CNOR® certified, and provides programs that reward and recognize its certified nurses. The CNOR® certification program is for perioperative nurses interested in improving and validating their knowledge and skills, while providing the highest quality of care to their patients. It is an objective, measurable way of acknowledging the achievement of specialty knowledge beyond basic nursing preparation and RN licensure. "It is an honor to be certified as CNOR® Strong once, but three years in a row is an even greater achievement," says Diane Wynn, MSN, RN, interim chief nursing officer, Long Beach Medical Center and Miller Children's & Women's. "We strive to continue to be CNOR® Strong for many years to come by taking steps to prepare our nurses for CNOR® certification and recertification." Long Beach Medical Center and Miller Children's & Women's provide resources such as study guides and practice tests for perioperative nurses to ensure success when the time comes to take the CNOR® certification exam. In addition, experienced nurses often team up to provide support for those working to become CNOR® certified by helping them study for the exam. These efforts aided in the hospitals' third consecutive CNOR® Strong designation. Research shows that nurses who earn the CNOR® credential have greater confidence in their clinical practice. Thus, a team of certified nurses who have mastered the standards of perioperative practice provides even more empowerment – further advancing a culture of professionalism and promoting improved patient outcomes. •

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INDUSTRY INSIGHTS

news & notes

Modicine PatientWear Introduces Surgical Undergarments Modicine PatientWear has announced a new, patient-focused line of high-quality surgical undergarments. Designed with patients in mind, Modicine PatientWear created the patented Modesty Bra and patent-pending Modesty Brief, which offer patients coverage without sacrificing quality care while in surgery. “Surgery can be very stressful and intimidating for a patient, and the added anxiety of being vulnerable and exposed only adds to the situation,” says Nathan Gray, CEO of Modicine Patientwear. “That’s why we decided to put the patient first and develop a first-of-its-kind surgical undergarment. We believe that alleviating this concern can better protect a patient’s dignity while getting needed treatment.” Modicine PatientWear was borne out of necessity. Dr. Scott Trenhaile, an orthopedic surgeon and company advisor, noticed

a colleague’s hesitation to undergo shoulder surgery for fear of being exposed on the operating table to the people she worked with every day. He knew there had to be a solution. The line features a Modesty Bra and Modesty Brief. Created for female shoulder and upper extremity procedures, the Modesty Bra is a comfortable bandeau that is made of a breathable, surgical-grade composite fabric. Men, women and children will take comfort in the Modesty Brief’s breathable surgical-grade material with an anti-migration band for added security. “Feeling comfortable in a high-stress environment isn’t gender specific,” said Trenhaile. “Being able to make someone feel comfortable when they’re under your care is an invaluable part of the doctor-patient relationship. Modicine PatientWear allows everyone in the operating room to feel empowered knowing the patient is comfortable.” •

St. Joe and Sacred Heart Announce New Facility The Watersound Origins community will soon welcome a new partner offering health care services. Commercial Real Estate Development LLC, a subsidiary of The St. Joe Company and Sacred Heart Health System, a provider of health care to children and adults in Northwest Florida, have entered into a lease for construction of a new health care facility at the entrance of the Watersound Origins community. The new health care facility initially plans to open as a 6,700

14 | OR TODAY | NOVEMBER 2018

square foot multi-specialty ambulatory clinic offering primary care and OB/GYN services. Plans for the health care facility would allow for future expansion to 13,000 square feet of space offering additional specialty care services. Design collaboration is currently underway between the parties with the expectation that construction of the facility will begin this fall, with an estimated completion date in 2019. •

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NuVasive, Siemens Healthineers Partner To Transform Spine Surgery NuVasive Inc. and Siemens Healthineers have announced a strategic partnership focused on technology development, marketing and commercial activities to advance clinical outcomes in minimally invasive spine surgery. NuVasive is focused on transforming spine surgery with minimally disruptive, predictable and clinically reproducible procedurally integrated solutions, while Siemens Healthineers offers surgeons a broad portfolio of imaging systems including 3D imaging for complex spine cases. In their Spine Precision Partnership, the companies will join forces in advancing their proprietary technologies with the objective of creating solutions which improve operating room (OR) workflow efficiency and provide increased precision in the delivery of minimally disruptive spine surgery technologies. The first step in the Spine Precision Partnership is to integrate NuVasive’s Pulse surgical automation platform with Siemens Healthineers’ Cios Spin* mobile 3D imaging for intra-operative quality assurance. (Cios Spin from Siemens Healthineers is pending 510(k) clearance, and is not yet commercially available in the United States.) “Currently, a number of hospitals and health care systems treat patients undergoing spine surgery through often cost-intensive, intra-operative CT scans with a general navigation system with limited utilization in spine surgery cases. The combination of NuVasive’s Pulse system and the Siemens Healthineers’ next-generation advanced imaging technology provides a compelling offering for hospitals and surgeons who require a scalable, cost-efficient technology that maximizes OR workflow efficiency and significantly improves visualization for spine surgery,” said Gregory T. Lucier, chairman and chief executive officer of NuVasive. “We firmly believe that this combined offering will enable advanced clinical benefits driving superior patient outcomes, delivered through greatly improved visualization of the anatomy promoting successful anatomical access and spinal implant placement.” “We at Siemens Healthineers are excited to work with NuVasive to develop intra-operative 3D-imaging and navigation tools for our advanced imaging systems that empower spine surgeons and neurosurgeons to be more precise, faster and cost efficient in the operating room. Increased workflow efficiency, better image quality, as well as predictable and reproducible results, will transform care delivery and set a new standard in spine surgery,” said Peter Seitz, head of surgery at Siemens Healthineers. •

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INDUSTRY INSIGHTS

news & notes

Healthcare System Invests in UVC Disinfection Robot McKenzie County Healthcare Systems Inc. is the first hospital in North Dakota to invest in Tru-D SmartUVC to help keep patients and staff safe from germs and hospital-acquired infections (HAIs). The grand opening of McKenzie County Healthcare Systems Inc.’s new medical facility took place June 22, 2018. This state-of-the-art, $76.3 million facility features a brand-new hospital and clinic as well as updates to the connected Good Shepherd Home (long-term care facility) and nearby Horizon Assisted Living. The facility is comprised of 24 inpatient rooms, nine emergency room bays and two operating rooms. “We are excited to have this innovative technology in our hospital, which will help maintain the cleanest, safest environment possible for our patients and staff,” said Dan Kelly, CEO of McKenzie County Healthcare Systems Inc. “As a new facility in the region, we hope to offer best-in-class care and service for residents in the area, and Tru-D will help elevate the level of care that we provide.” Tru-D is a UVC disinfection robot that is deployed after the environmental services staff cleans a room using traditional protocols. Operated from a remote control outside the room, Tru-D administers a single, lethal dose of UVC energy from one, central placement in the room, killing up to 99.9 percent of germs and pathogens that can be left behind. Once the cycle is complete, the operator is notified via audio and/or text message that Tru-D can be moved to the next room. • For more information, visit tru-dpowerofone.com.

AORN Syntegrity Inc., Syus Launch Benchmarking Product AORN Syntegrity Inc. and Syus announced the launch of Periop Insight, the first benchmarking tool to enable safety and efficiency comparisons across multiple facilities and hospital systems. With Periop Insight, administrators and perioperative leaders can improve operational and clinical decision-making and, ultimately, achieve better patient outcomes and financial results. Designed for clinicians, Periop Insight benchmarking is a new component of Periop Insight analytics that is powered by Syus, the industry leader in OR analytics, and AORN Syntegrity, the only evidence-based standardized perioperative documentation system for electronic health records (EHR). Periop Insight

captures EHR, supply, and human resources systems’ data for performance validation and hosts this information in a single, secure data warehouse. Today, the HIPAA-compliant benchmarking database contains more than 4 million cases and 25,000 surgeons from health care facilities across the United States and fully represents geographic distribution, size, volume, ownership and case complexity. All benchmark participant cases are mapped to standard data definitions including procedure, specialty, patient status and anesthesia method and participants can examine the data at any time to compare their operational measures to like facilities based on 14 performance measures. •

VISIT ORTODAY.COM FOR MORE INDUSTRY INSIGHTS.

16 | OR TODAY | NOVEMBER 2018

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INDUSTRY INSIGHTS webinar

SSI Presentation Delivers Valuable Content Staff report he OR Today webinar “Do You Have Skin in the Game? The High Stakes of SSIs” was sponsored by 3M Health Care. Anna Cypert, BSN, RN, a clinical specialist with 3M Infection Prevention Division, presented valuable information every perioperative professional can use.

Cypert discussed how patient preparation is fundamental to the prevention of surgical site infections by examining the CDC’s conceptual formula for SSI risk in relation to patient and process variables. Cypert has been a nurse for over 20 years. She began her nursing career as a LVN, then an RN; going on to earn a BSN from the University of Texas Medical Branch in Galveston. Prior to working for 3M, Cypert worked for the Memorial Hermann Hospital System in Houston, Texas. At Memorial Hermann, she provided direct care to patients in an acute-care setting. She is working toward a CIC (Infection Prevention Certification) focusing on nurse-to-nurse/clinician education committed to reducing the risks of surgical site infections and promoting positive and measurable clinical outcomes. Approximately 150 people attended the live webinar which is now available for viewing online. The presentation received positive reviews in a post-webinar survey and a 4.1 ranking on a 5-point scale. “This was my first OR Today webinar and I found it very informative. I now have some great topics to take back to my SSI task force team,” said M. Love, surgical clinical quality reviewer.

18 | OR TODAY | NOVEMBER 2018

“I love the evidence-based practice information to provide the best care to our patients. Learning about the nasal, skin and oral prepping has been invaluable,” said OR Supervisor M. Van Winkle. “For those who missed ‘Do you have skin in the game,’ they really missed out! What an outstanding presentation! I would love to attend it again because there was so much valuable information,” said B. Holder, QI/IC officer. “This is the second webinar that I have listened in on. They are very eye opening and provide so much great information. Keeping up with all the new information is great for keeping up with the fast-paced world of medicine. The more you know the more helpful you can be,” explained Infection Preventionist S. LaMuro. “OR Today’s webinar was beneficial for anyone trying to make a difference in patient lives,” said Infection Prevention Manager A. Pojero. “This was a great webinar, very interesting. It’s a topic that we probably all think we know very well, but I would say even the most seasoned nurses would have very good information to take away,” said B. Byrd, clinical educator surgical services. “This was a very informative webinar. This was the first time I have seen such an in-depth comparison of the different pre-surgical preps and feel it will be very useful in practice. I understand now why the different preps have different uses,” said J. Marr, unit educator OR. “I loved the SSI risk formula as a visual representation of cutting in half the dose of bacteria and the important

mention of outpatients where there is an uncontrolled home environment,” shared Quality/Risk Manager H. Eason. The OR Today webinar series as a whole also received praise. “I really enjoy the webinars that OR Today offers. Always informative and well done,” said Clinical Specialist D. Walker. “OR Today webinars offer an excellent medium to stay abreast of current events needing attention in the OR,” said E. Anderson, RN. “OR Today’s webinars clearly convey the intended message to the audience in an easy to follow way, providing useful information that can be applied to daily perioperative practice,” said CNOR/Circulating Nurse S. Faw. “I have listened to several of OR Today’s webinars and they all are subject matters that have an effect on our practice as perioperative nurses,” said Assistant Director Surgical Services S. Holland. “OR Today’s webinars are a great way to learn new insights for optimal patient care in the operating room. They also offer follow-up information if one would like to gain more information or resources to enhance their knowledge of webinar topics,” said Perioperative Educator K. Gruchow. For more information, visit ORToday.com. Sponsored by:

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The sterile field should be covered if it will not be immediately used or during periods of increased activity. – AORN 2019*

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AORN Guideline for Sterile Technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 2018: electronic release.*

COMPANY SHOWCASE Medline

A Multi-faceted Decolonization Bundle

for Surgical Site Infection Prevention THE LANDSCAPE OF SURGICAL SITE INFECTIONS Surgical site infections (SSIs) are devastating; they worsen patient outcomes by adding new morbidities and increasing mortality risk, and add significant direct and indirect financial costs to facilities and patients.1 SSIs are among the most frequent hospital acquired infection.2 The most common microbial cause of SSIs in community hospitals is methicillin-resistant Staphylococcus aureus (MRSA).3 SSIs caused by MRSA are indicative of the larger trend of drug resistant pathogens causing SSIs, as one study found that 60% of infected surgical wounds contained microorganisms demonstrating antibiotic resistant patterns.4 Despite the above data, SSIs are considered largely preventable when following a holistic approach to infection control.5 The practice of preoperative decolonization has been demonstrated to play a critical role in an overarching SSI prevention protocol.6

COLONIZATION AND INFECTION RISK Bacteria have inhabited humans for millennia, such that each person carries a rich microflora containing trillions of microorganisms, almost all of which are beneficial or at least harmless. However, pathogenic microorganisms, such as S. aureus, can colonize a patient without causing any symptoms of an infection. Nonetheless, patients who are carriers of pathogenic bacteria are more likely to develop an SSI, since the bacteria are already present in the patient and can more easily migrate to the incision, causing an SSI.7 Pre-operative application of broad spectrum antiseptic agents can reduce the potential for a patient to develop an SSI.6 Moreover, since patients can be cocolonized â&#x20AC;&#x201C; the state of multiple

20 | OR TODAY | NOVEMBER 2018

pathogenic bacteria colonizing a patient simultaneously â&#x20AC;&#x201C; the application of a horizontal approach that kills numerous species of microorganisms can be beneficial. This preventative approach is also positioned well to counter the incidence of multi-drug resistant organism (MDRO) colonization, since antiseptic agents such as chlorhexidine gluconate (CHG) and povidone-iodine (PVP-I) demonstrate antiseptic activity against several MDROs.6,8 As part of a holistic SSI reduction program, the application of broad-spectrum antiseptics can be applied to targeted areas that are most likely to be colonized.

NASAL DECOLONIZATION WITH POVIDONE IODINE NASAL SWABS Gram-positive organisms, such as S.

aureus, frequently colonize the skin and nasal mucosal membranes.7 Historically, the antibacterial agent mupirocin has been the standard method of decolonizing the nares prior to surgery, but the possibility of resistance, along with barriers to patient compliance, have led to a search for alternative solutions; in that search, PVP-I antiseptic nasal swabs have emerged as a potential alternative. PVP-I demonstrates activity against gram-positive and gram-negative bacteria, including MRSA,6 and does not appear likely to lead to resistance.9 Additionally, two studies report no difference in SSI rates when comparing mupirocin treated patients to those treated with PVP-I.10,11 Finally, data suggest that decolonization with PVP-I costs less than mupirocin treatment, and patients preferred nasal decolonization with PVP-I compared to mupirocin.11,12

ORAL AND SKIN DECOLONIZATION WITH CHLORHEXIDINE GLUCONATE CHG is likely the most widely used antiseptic in health care, largely due to its long history of use, broad-spectrum activity, and low incidence of adverse events.13 Preoperative decolonization protocols often include bioburden reduction of the skin with CHG bathing, especially at the surgical site, as it is well established that the skin is frequently colonized with numerous pathogenic bacteria. Indeed, preoperative skin decolonization with CHG, often along with nasal decolonization, has been shown to significantly reduce SSIs.6 WWW.ORTODAY.COM

COMPANY SHOWCASE Medline

In addition to the skin and nares, the oral cavity harbors significant amounts of bacteria, and therefore represents a preoperative target for decolonization. Given the broad-spectrum antimicrobial activity of CHG, use of a CHG oral rinse can reduce the bioburden in the oral cavity, thereby minimizing transmission of oral bacteria to the surgical site. Lastly there is little evidence to suggest CHG usage leads to resistance, providing an advantage over antibiotic prophylaxis.6

A BROAD-SPECTRUM, TARGETED, BUNDLE FOR DECOLONIZATION The implementation of a pre-operative bundle consisting of nasal decolonization with PVP-I swabs, oral decolonization with an oral CHG rinse, and skin decolonization with CHG bathing, has been associated with a significant reduction in SSIs.14 Moreover, the authors of this study report that compliance with the preoperative protocol was 100%. Medline Industries, Inc. provides the necessary components to implement an evidence-based, preoperative decolonization protocol. Medline’s 2% CHG Skin Cleansing Kit provides four fluid ounces of a 2% CHG solution along with six dry wipes for application. In addition, Medline offers a Nasal & Oral WWW.ORTODAY.COM

Antiseptic Cleansing Kit containing four PVP-I antiseptic nasal swabs, and 0.51 fluid ounces of a 0.12% CHG oral rinse, complete with several devices allowing for multiple modes of administration. These products represent a convenient, yet multi-faceted, approach to preoperative decolonization in an effort to help prevent SSIs. For more information, visit www.medline.com.

REFERENCES 1. Leaper D, Ousey K. Evidence update on prevention of surgical site infection. Curr Opin Infect Dis. 2015;28(2):158-163. 2. Sievert DM, Ricks P, Edwards JR, et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention,2009-2010. Infect Control Hosp Epidemiol. 2013 Jan;34(1):1-14. 3. Anderson DJ, Sexton DJ, Kanafani ZA, Auten G, Kaye KS. Severe surgical site infection in community hospitals: Epidemiology, key procedures, and the changing prevalence of Methicillin-Resistant Staphylococcus aureus. Infect Control Hosp Epidemiol. 2007; 28(9): 1047-1053. 4. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014; 370: 1198–208. 5. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mor-

tality and costs. Infect Control Hosp Epidemiol. 2011; 32: 101–114. 6. Septimus EJ & Schweizer ML. Decolonization in prevention of health care-associated infections. Clin Microbiol Rev. 2016; 29:201-222. 7. Wertheim HF, Melles DC, Vos MC, et al. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis. 2005; 5: 751–762. 8. Hill RL, Casewell MW. The in-vitro activity of povidone-iodine cream against Staphylococcus aureus and its bioavailability in nasal secretions. J Hosp Infect. 2000; 45: 198–205. 9. Lanker Klossner B, Widmer HR, Frey F. Nondevelopment of resistance by bacteria during hospital use of povidone-iodine. Dermatology. 1997; 195 Suppl2: 10-13. 10. Phillips M, Rosenberg A, Shopsin B et al. Preventing Surgical Site Infections: A Randomized, Open-label Trial of Nasal Mupirocin Ointment and Nasal Povidone Iodine Solution. Infect Control Hosp Epidemiol. 2014; 35(7): 826-832. 11. Torres EG, Lindmair-Snell JM. Is preoperative nasal povidone-iodine as efficient and cost-effective as standard methicillin-resistant Staphylococcus aureus screening protocol in total joint arthroplasty? J Arthoplasty. 2016; 31: 215-218. 12. Maslow J, Hutzler L, Cuff G, Rosenberg A, Phillips M, Bosco J. Patient experience with mupirocin or povidone-iodine nasal decolonization. Orthopedics. 2014 Jun;37(6):e576-81. 13. McDonnell G & Russell AD. Antiseptics and disinfectants: Activity, Action, and Resistance. Clin Microbiol Rev. 1999; 12(1): 147-179. 14. Bebko SP, Green DM, Awad SS. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. JAMA Surgery. 2015; 150(5): 390-395.

NOVEMBER 2018 | OR TODAY |

One Comprehensive Solution. Just as important as handwashing, manual cleaning and antibiotic stewardship are to preventing SSIs, so is disinfecting the OR from top to bottom. Tru-D’s evidence-based solution has been proven to improve patient safety by complementing your existing infection reduction protocols. Tru-D’s unique, programmatic approach to UVC disinfection and commitment to excellent customer experiences, results in substantial cost savings and improved patient outcomes, hospital-wide. If you are interested in learning more, visit us at tru-d.com.

TRU-D.COM • 800.774.5799

IN THE OR

market analysis

UV Disinfection Growth Continues Staff report s health care providers continue to focus on the reduction of healthcare acquired infections (HAIs) and surgical site infections (SSIs), the ultraviolet (UV) disinfection market is on the rise. Additional factors powering the growth of this market include the importance being place on patient outcomes and patient satisfaction.

Last year, reports suggested that the market for ultraviolet-C (UVC) disinfection was expected to hit $80 million by the end of the year. In fact, UVC disinfection was such a popular topic that the ECRI Institute included it on its 2017 C-Suite Watch List. “The UV-C technology segment dominated the global environmental disinfection robots market and is expected to lead the market over the next four years. The growth of this segment is attributed to the fact that an increasing number of hospitals and health care facilities will invest in automating their disinfection process to combat against HAIs. This segment is likely to grow further as more hospitals and other health care facilities will invest in automating their disinfection process,” according to MarketResearchReports.biz. Geographically, the Americas are expected to dominate the market for the next 5 years, the report added. Some major manufacturers in the UV-C disinfection market are Bioquell, STERIS, The Clorox Company, Tru-D SmartUVC, Xenex, Advanced Sterilization Products (ASP), Blue Ocean Robotics, Infection Prevention Technologies, Surfacide and UVC Cleaning Systems. WWW.ORTODAY.COM

The overall importance of this market can be realized by looking at similar markets within heath care. For example, a surface disinfectant market report by MarketsandMarkets, predicts that the surface disinfectants market is expected to reach $789.1 million by 2022 from $529.6 million in 2017. The increasing number of surgical procedures, rising geriatric population and subsequent growth in the prevalence of chronic diseases are major factors that are driving the growth of this market. Additionally, the MarketsandMarkets report states “the surface disinfectants market is segmented into hospitals, clinical laboratories, pharmaceutical companies, and other end users. The hospitals segment holds the largest share in the market. The growth is primarily attributed to the rising incidence of HAIs and growth in the number of hospitals in emerging countries.” The amount of funds dedicated to disinfection along with a growing emphasis on the reduction of SSIs and HAIs seem to indicate a potential for huge growth in the health care segment of the UV-C disinfection market. Leaders from companies that manufacturer these devices see a positive future for the industry. “The UVC disinfection market has grown exponentially in the past five years as hospitals have been more receptive to adopting the technology. Part of this shift is due to HAI rates increasing, more superbugs discovered each year and increased financial accountability for infection rates,” said Chuck Dunn, CEO of Tru-D SmartUVC. “Hospitals are realizing that it’s critical to provide the cleanest environments possible to protect patients and

staff from infections.” “The AHA and CDC recently published new guidelines, ‘Using the Health Care Physical Environment to Prevent and Control Infection,’ which suggests best practices for cleaning and disinfection, including the use of no-touch disinfection technology. Tru-D is a type of no-touch disinfection with clinically validated results in HAI reduction and ease of integration into hospital workflows,” he added. “As prominent organizations such as the AHA, CDC and ASHE begin to stress the use of enhanced terminal room disinfection technology, we believe UVC disinfection will become a standard of care for health care facilities.” Xenex Vice President of Sales and Account Management Irene Hahn agrees that the market is on the rise. “OR Directors are definitely looking at ways to address surgical site infections (SSIs) and our conversations with them have changed dramatically over the past couple of years. We are no longer explaining what UV disinfection is,” Hahn explained. “They have reviewed the peer-reviewed studies from hospitals that experienced fewer SSIs after they used LightStrike robots for room disinfection, and they are interested in how pulsed xenon UV can fit into their daily operations.” “We’ve seen facilities invest in our technology because they want to begin offering new surgical services, such as outpatient joint procedures, and they understand the need for the cleanest environment possible to reduce the risk of an infection. As patients increasingly choose to go to ASCs for complex procedures, it’s critically important that the facility is providing a clean environment,” Hahn said. NOVEMBER 2018 | OR TODAY |

IN THE OR

product focus

Clorox Healthcare®

Optimum-UV Enlight® System The Clorox Healthcare® Optimum-UV Enlight® System is an all-in-one solution providing powerful surface treatment enhanced by ultraviolet-C (UV-C) technology to kill more than 30 HAI-causing pathogens including Clostridium difficile spores, CRE, VRE and MRSA, in five minutes at eight feet, for superior infection prevention and patient safety. The Optimum-UV Enlight® System provides the optimal balance of strong performance, quality, user-friendly design and affordability, with advanced data collection and reporting capabilities that help healthcare facilities ensure they are maximizing device usage and getting the efficacy they are counting on. •

Diversey

MoonBeam™3

Diversey’s MoonBeam™3 ultraviolet-C disinfection device provides the optimum angle for disinfection. This portable, powerful solution disinfects quickly, reliably and responsibly. MoonBeam3 is cost effective and designed for fast, on-demand disinfection of surfaces. The system offers three individually-adjustable arms that can be positioned at almost any angle to target the UV-C light to surfaces in the OR (both horizontal and vertical), optimizing disinfection energy and dosing for environmental surfaces and non-critical equipment, in as little as 3 minutes. • For more information, visit www.diversey. com/uv-disinfection/moonbeam or www. SDFHC.com.

24 | OR TODAY | NOVEMBER 2018

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IN THE OR

product focus

Surfacide Helios

Helios by Surfacide is a patented triple emitter UV-C hard surface disinfection system that data indicate eradicates multi-drug resistant organisms, including C.Diff, MRSA, VRE, CRE and Acinetobacter. Designed to precisely target all areas – even those hidden by shadows – the Helios system’s advanced laser mapping technology scans a room, creates a plan and gets to work. The Helios UV-C system uses three light emitting towers to safely and effectively disinfect all areas of a hospital room, including tough to reach areas like bathrooms. Environments are safely disinfected and ready for use in just one efficient cycle. •

Tru-D

SmartUVC Tru-D SmartUVC is a portable UVC disinfection robot that delivers one automated, measured dose of UVC to consistently disinfect an entire room, resulting in the ability to document disinfection results after each and every Tru-D room treatment. Tru-D operates from one placement within the OR, ensuring significant percent pathogen reduction in direct and shadowed areas and eliminating the threat of human error in the disinfection process. Validated by the first-ever randomized clinical trial on UVC disinfection, the “Benefits of Enhanced Terminal RoomDisinfection” (BETR-Disinfection) study, results proved that adding enhanced terminal room disinfection strategies including the use of Tru-D reduces the risk of acquisition of infection of four major MDROs and also has an indirect effect on every patient who enters a hospital’s doors. •

WWW.ORTODAY.COM

NOVEMBER 2018 | OR TODAY |

IN THE OR

product focus

Xenex

LightStrike™ Germ-Zapping Robots™ Disinfection technology has taken a leap forward with Xenex LightStrike™ Germ-Zapping Robots™. Providing safe and efficient OR disinfection via intense pulsed xenon UV light, LightStrike robots are utilized for terminal cleans, yet fast enough for between case cleaning too. A recent study conducted at MD Anderson Cancer Center found that a 2-minute cycle of pulsed xenon UV eliminated 72% more pathogens on high-touch surface areas in the OR than manual cleaning alone. Proven effective in 9 HAI reduction studies, LightStrike robots are the only UV disinfection technology credited by hospitals in peer-reviewed, published studies for helping them reduce their SSI rates by 46-100%. • For more information, visit www.xenex.com.

26 | OR TODAY | NOVEMBER 2018

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Powerful performance It’s okay to ask more of your surgical prep. 3M™ SoluPrep™ Film-Forming Sterile Surgical Solution is a powerful tool in the fight against SSIs. Designed for the realities of surgery, it combines the antimicrobial efficacy of CHG with 3M polymer science to create a surgical prep that sticks.

3M™ SoluPrep™ Film-Forming Sterile Surgical Solution

Is the first and only FDA-approved prep with sterile solution.

Offers 96 hours of antimicrobial persistence.1

Has 3M™ Prep Protection Film for CHG staying power.

3M™ SoluPrep™ Film-Forming Sterile Surgical Solution chlorhexidine gluconate (2% w/v) and isopropyl alcohol (70% v/v) Patient Preoperative Skin Preparation

1. Data on file 3M Study EM-05-013603, 3M Health Care.

Fight SSIs from every angle.

IN THE OR

continuing education

IN THE OR

CE446

continuing education

Balancing Act: Managing Fluid Intake and Output in the Surgical Patient Lisa M. Riedel, DNP, CRNA, and Debra Anscombe Wood, BSN, RN

he body requires that a level of homeostasis, or constancy, be maintained during the many changes that occur in the internal and external environments. Cardiovascular, neurological, and neuromuscular functions can quickly be altered due to fluid and electrolyte balance.1 Surgical patients are at increased risk of imbalance of fluid and electrolytes because of preoperative fluid and food restrictions, and because of intraoperative fluid and blood loss.2 Bowel preparations, nasogastric suctioning, vomiting, and certain disease states also place patients at risk for fluid volume deficit before surgery.2 Anesthesia and surgery further reduce fluid volume. Recovery from anesthesia and surgery causes fluid shifts and imbalances. Postoperative nausea and vomiting or the inability to resume normal oral intake can further deplete the surgical patient.2,3

Nurses need to understand fluid management from the preoperative to the postoperative period to effectively care for surgical patients. This module discusses fluid management in the adult surgical patient from the preoperative period to the postanesthesia unit (PACU). The module addresses the IV fluids administered and how replacement is calculated.

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Fluid Fundamentals Fluids and electrolytes play an important role in the human body. The average adult human body is about 60% water.4 Water content varies depending on a patient’s age, sex, and body mass. Two-thirds of that fluid is inside the cells (intracellular or ICF), and the remaining one-third is outside of cells (extracellular or ECF).4 Muscle tissue contains more water than the same amount of adipose tissue. Therefore, men generally have higher water content because of more lean body mass — more muscular tissue — than women.4 Bodily fluids serve many essential functions, such as maintaining body temperature, transporting oxygen and nourishment to cells, and removing waste products of cellular metabolism.4 Body fluids maintain homeostasis by removing waste products of cellular metabolism. Electrolytes are the substances found in the ICF and ECF.4 Electrolytes dissociate into ions, which are charged particles, when dissolved in water. Correct electrolyte balance is essential for maintaining contractility of muscles (skeletal and cardiac), regulating acid-base balance, transmitting nerve impulses, regulating water distribution, clotting blood, and generating adenosine triphosphate needed for cellular energy. The major cations, or positively charged electrolytes, are sodium, potassium, calcium, and magnesium. The major anions, or negatively charged electrolytes, are chloride, phosphate, bicarbonate, and plasma proteins. ICF and ECF have essentially the same

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

Goal and objectives The goal of this continuing education program is to inform nurses about fluid management of the adult surgical patient. After studying the information presented here, you will be able to: • Describe the role of fluids and electrolytes in homeostasis • Identify the causes of fluid volume deficit before surgery • Explain the calculation of fluid deficit and replacement volume

NOVEMBER 2018 | OR TODAY |

IN THE OR

continuing education electrolytes but in different concentrations. Potassium and phosphorus dominate in the ICF, while sodium and chloride dominate in the ECF. The renal and pulmonary systems maintain fluid and electrolyte balance.4 The anesthetics used in surgery alter the surgical patient’s normal physiologic state — including electrolyte levels.5

substances of high molecular weight that do not easily cross the capillary membrane.4 This draws fluid into the intravascular space and causes a sustained increase in intravascular volume.4 Because colloids tend to remain intravascularly, there is less peripheral edema, and a smaller volume is required for resuscitation. The downside is that colloids are expensive 6 and can cause coagulopathy. Distribution of Body Electrolytes Examples of colloid solutions Gram molecular Intracellular Interstitial Intravascular are albumin 5% and 25% weight (mEq/L) (mEq/L) (mEq/L) (Albuminar), dextran (dextran 40), and hetastarch (Hespan).1 Sodium 23.0 10 142 145 Surgical patients also may Potassium 39.1 140 4 4 receive blood or blood component transfusion therapy. Calcium 40.1 <1 3 3 Packed red blood cells are the most common blood Magnesium 24.3 50 2 2 product administered. Packed Chloride 35.5 4 110 105 red blood cells maintain intravascular blood volume Bicarbonate 61.0 10 28 24 and improve oxygen-carrying capacity and oxygen transport Phosphorus 31.0 75 2 2 to tissues. Fresh frozen plasma, Protein (g/dL) — 16 2 7 platelets, and cryoprecipitate — a blood product prepared from plasma — are given intraoperaIntra Versus Extra Replacement Fluids in the OR tively to improve coagulation as well Total body water is divided into two Because most cases of hypovolemia 4 as increase fluid volume in the surgical compartments: ICF and ECF. ICF is are caused by a loss of ECF, replace1 patient. The amount and type of blood the fluid found within cell membranes. ment with isotonic crystalloids, which component therapy are documented on ECFs are fluids in the compartments have a composition similar to ECF, 1 the anesthesia intraoperative record. outside the cells of the body: plasma, is appropriate. Examples of isotonic intravascular fluids, fluids in the GI solutions are lactated Ringer’s and tract, and cerebrospinal fluid. The 0.9% normal saline. Solutions containHeart Basics extracellular and the intracellular fluid ing dextrose are not usually adminisThe cardiovascular system is composed compartments are separated by a cell tered intraoperatively, because of the of the heart, acting as a pump, and the membrane. Hypovolemia, or volume risk of hyperglycemia, or high blood vasculature that carries blood. Blood depletion, generally refers to a loss of sugar.1 Hyperglycemia can result in pressure is the pressure of arterial blood ECF. osmotic diuresis, which is increased against artery walls. The pressure is Fluids and electrolytes move beurination caused by the presence of the result of two forces: the heart as it tween the intracellular and extracellucertain substances, such as dextrose, in pumps blood into arteries and through lar spaces to facilitate body processes. the kidney tubules. This exacerbates the circulatory system and the force These processes are acid-base balance, volume depletion.8 of the arteries as they resist the blood tissue oxygenation, response to drug While isotonic solutions are the flow.9 Cardiac output is the volume of therapies, and response to illness. first line of fluid volume replacement, blood being pumped by the heart. It is The intravascular fluid (IVF) and the some surgical patients require more equal to the heart rate multiplied by interstitial fluid (ISF) are the two aggressive therapy, which can include the stroke volume. Thus, variation is compartments of extracellular fluid. both colloid solutions and blood comdetermined by changes in extracellular The capillary membrane separates the ponent therapy. Colloids are solutions fluid volume, the contractile state of IVF and the ISF compartments. The containing osmotically active protein the heart, and vascular tone.10

30 | OR TODAY | NOVEMBER 2018

intravascular space is the fluid compartment accessible to the clinician and the chief focus of fluid therapy.4 The three goals of fluid therapy during surgery are to provide maintenance fluids, to replace fluids lost because of surgery and anesthesia, and to correct electrolyte imbalances.7

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IN THE OR

continuing education

Hypotension is defined as a blood pressure 20% less than baseline or preoperative blood pressure and is an indicator of hypovolemia.11 Decreased vascular resistance causes relative hypovolemia by interfering with venous return to the heart.11 Decreased vascular resistance (vasodilation) can be related to medication, general anesthesia, or regional anesthesia. Veins are very distensible and contain about 60% of blood volume.12 Hypervolemia (fluid volume excess) is defined as too much fluid in the vascular space, a condition that results in hypertension and is usually not seen in the surgical patient. Hypertension is defined as a blood pressure 20% to 30% above baseline.11 The venous system helps maintain cardiac output through its ability to accommodate large volume changes, buffering periods of hypervolemia or hypovolemia.7

Latest on Fasting Anesthesia for surgery suppresses the swallowing mechanism. When this mechanism is partially or totally paralyzed, food and fluids can enter the airways. These substances are not easily removed and cause a serious inflammatory condition known as aspiration pneumonia.13 Many institutions follow the NPO after midnight protocol.14 This restriction of food and fluid is safe and simple. In 1999, the American Society of Anesthesiologists Task Force on Preoperative Fasting set forth a revised standard, calling for cessation of clear liquids two hours before surgery and a light meal no later than six hours before surgery.13 According to the society, patients may be better hydrated and have less nausea after surgery when these revised practice guidelines are followed. The indication for surgery and concurrent medical conditions may also contribute to volume deficits. Vomiting, diarrhea, and fever cause dehydration. Bowel preparations, nasogastric suctioning, and certain medications WWW.ORTODAY.COM

(e.g., diuretics, steroids) further add to fluid volume deficits. The perioperative nurse and anesthesia provider review laboratory values before surgery to assess for fluid and electrolyte imbalances and correct them before surgery.11 Certain disease states, such as diabetes mellitus, liver disease, or renal insufficiency, increase a patient’s risk for fluid and electrolyte imbalances. Burns cause an increase in permeability at the site of injury and throughout the microvasculature. This causes a tremendous shift of fluid from the plasma volume to the interstitial space.15 The burn patient is therefore intravascularly depleted. Patients who have undergone diagnostic procedures requiring IV contrast media, such as an arteriogram or pyelogram, may experience osmotic diuresis because of urinary excretion of water and electrolytes.7 This diuresis causes hypovolemia. All of these factors must be considered as the patient enters the surgical suite.

First, Second, Third Spacing The surgical patient requires fluid therapy to replace losses that accompany surgery. Evaporative loss from exposed viscera and manipulation of tissues during surgery leads to redistribution of fluid from the intravascular space to the interstitial space. Fluid spacing is a term used to classify the distribution of water in the body. First spacing is the normal distribution of fluid in both the extracellular and intracellular compartments.16 Second spacing refers to an excess accumulation of interstitial fluid (edema). The interstitial compartment acts as an overflow reservoir for the intravascular compartment.16 Third spacing occurs when fluid accumulates in areas that normally have no fluid or only a minimum amount of fluid, such as the peritoneal, pleural, and pericardial cavities. Third spacing traps fluid away from the normal fluid

compartments and results in a deficit in extracellular fluid volume.16 Thirdspaced fluid is nonfunctional. Surgical trauma causes third spacing because traumatized, inflamed, or infected tissue — as occurs with burns, extensive injuries, surgical dissections, or peritonitis — can sequester large amounts of fluid in its interstitial space. This fluid shift cannot be prevented by fluid restriction and is at the expense of both the functional extracellular and the intracellular fluid compartments.2 Calculation of fluid replacement depends on the extent of the surgical procedure and visceral exposure to drying components. For example, a patient undergoing a laparoscopic procedure has a smaller amount of exposed viscera, while a patient undergoing a laparotomy has a large amount of exposed viscera.2 Thus, even though carbon dioxide causes a visceral drying process, the laparotomy patient requires more aggressive IV fluid replacement despite frequent organ irrigation during the surgical procedure.2

How Much Fluid? During the intraoperative period, the anesthesia team replaces fluids according to the length of time a patient is NPO, the fluids lost during surgery and anesthesia, and the patient’s physiologic factors that influence fluid management. Fluid estimates for otherwise healthy adults undergoing elective operations are:17 • GI losses of 100 milliliters to 200 milliliters a day • Insensible losses of 500 milliliters to 1,000 milliliters a day • Urinary losses of 1,000 milliliters a day • Predicted daily maintenance requirement of 2,500 milliliters a day17 The calculation below can be used to estimate maintenance fluid requirements:7 • 4 mL/kg/hr for the first 0 to NOVEMBER 2018 | OR TODAY |

IN THE OR

continuing education 10 kg 2 mL/kg/hr for the next 11 to 20 kg • 1 mL/kg/hr for weight greater than 21 kg7 Deficit is defined as the time the patient is NPO to the time surgery begins. The deficit can be estimated by multiplying the normal maintenance rate by the length of the fast. For the average 70-kg (155-pound) person fasting for eight hours, this amounts to: • 4(10kg) + 2(10kg) + 1(50kg) mL x 8 hours = 880 mL Fluids lost to bowel preparations and nasogastric suctioning is added into this calculation of deficit.2 Because of this and how hypovolemia can affect cardiovascular system, mechanical bowel preparation is no long a standard of care.18 Fluid therapy for surgical patients includes administration of crystalloids to compensate for preoperative fluid deficit, and maintenance fluids to compensate for evaporative losses from exposed viscera and to provide solute for excretion of waste and fluids to replace surgical fluid losses (e.g., third-space loss and blood loss).18 Physiologic maintenance is defined as the time from incision to closure and depends on the type and duration of the surgical procedure performed and the patient’s weight in kg. For surgical procedures deemed minor, an estimate of 4 mL/kg/hr is used; moderate surgical procedures warrant 6 mL/kg/hr, and extensive surgeries 8 mL/kg/hr. Another factor taken into consideration is blood loss. Blood loss is replaced 3:1 with isotonic crystalloid solution, 1:1 with colloid solution, and 1:1 with replacement blood products.19 The schedule for fluid replacement during the surgical procedure is:20 • First hour: 1/2 the deficit + maintenance + blood replacement •

32 | OR TODAY | NOVEMBER 2018

•

Second hour: 1/4 the deficit + maintenance + blood replacement • Third hour: 1/4 the deficit + maintenance + blood replacement Using the above example of a 70-kg patient fasting for eight hours having a moderate procedure with 100 mL of blood loss in the second hour of the case: • 1/2 (880) + 6(70) + 0 = 860 • 1/4 (440) + 6(70) + 3(100) = 830 • 1/4 (440) + 6(70) + 0 = 530 • Total for case = 2,220 mL These calculations are a guideline for fluid replacement. Fluids will be titrated based on patient response and coexisting diseases.

Anesthesia’s Effects Anesthesia contributes to the fluid volume deficit of surgery. Vasodilation caused by anesthesia can result in hypotension.20 Different types of anesthetic techniques are used based on patient factors and type of surgery performed. The type of anesthetic has varying effects on patient hemodynamics and affects the amount of fluid replacement needed. Deep sedation, a state in which the patient is asleep but easily arousable, does not have the degree of hemodynamic compromise as does administration of a general anesthetic, but it is still a concern.21 General anesthesia involves a complete loss of consciousness and amnesia. General anesthesia is a reversible state that provides analgesia, muscle relaxation, and sedation by IV and/or inhaled anesthetics. Inhaled anesthetics (e.g., desflurane, sevoflurane, isoflurane) cause peripheral vasodilation and are myocardial depressants. This leads to dose-dependent decreases in myocardial contractility and blood pressure. Patients who are volume depleted, are overdiuresed, or have poor ventricular function are at higher risk.11

Spinal and epidural anesthesia involve using local anesthetics to block conduction pathways along spinal nerve roots to provide anesthesia to the body below the level of the injection site. This also causes vasodilation in all areas below the level of analgesia. Peripheral vasodilation causes pooling of blood, fluid volume deficit (a relative hypovolemia), and reduced venous return to the heart. Hypotension results secondary to this relative hypovolemia.11

Fluid Overload Patients with congestive heart failure (CHF), renal insufficiency, or cirrhosis of the liver may not tolerate fluid replacement therapy. Compensatory mechanisms that can be relied on in younger patients function less rapidly in older patients. The elderly have less compliant atrial and ventricular myocardium and decreased passive left ventricular filling. Elderly patients are less able to maintain the integrity of the extracellular space and other fluid compartments when challenged. These physiologic changes of aging place the elderly patient at risk for fluid volume overload.22 In CHF — which is associated with systemic hypertension and coronary artery disease — the heart’s pumping power is weaker than normal. The more fluid in the blood vessels, the harder the heart must work to pump excess fluid through the body. Overaggressive fluid administration can place the patient with CHF at risk for pulmonary edema. A patient with poorly functioning kidneys cannot diurese, causing fluid to remain in the vascular space, resulting in volume overload. A patient in liver failure has generalized peripheral vasodilation and a hyperdynamic circulatory system with fluid and electrolyte imbalances that require judicious intraoperative fluid management. Fluid therapy is guided around these factors. WWW.ORTODAY.COM

IN THE OR

continuing education

Composition of IV Fluid23 Solution ECF

Tonicity -

Na+

Cl-

K+

Ca++

Mg++

Glucose

Lactate

142

108

4.2

1.3

0.8

5.6

1.2

Normal saline

Isotonic

154

Lactated Ringer’s

Isotonic

130

109

D5-1/4 NS

Isotonic

38.5

After Surgery When a patient is transferred from the OR to the recovery room, the anesthesia provider gives a report to the nurse receiving the patient. The total amount of fluid given in crystalloid, colloid, and blood component therapy is reported and recorded in the anesthesia record. Estimated blood loss and urine output are reported, as is the duration of surgery along with type of anesthesia administered. One cause of hypotension in the PACU is inadequate replacement of intraoperative fluid.11 Manifestations of hypotension include disorientation, nausea, loss of consciousness, chest pain, oliguria (decreased urination), and anuria (no urination). These can be attributed to the hypoperfusion that accompanies hypotension. Hypotension and sinus tachycardia (i.e., a heart rate greater than 100 beats per minute in adult patients) is an insensitive and nonspecific indicator of hypovolemia. An increased heart rate is detrimental for two reasons. Tachycardia increases the heart’s cardiac oxygen requirements at the same time it decreases myocardial oxygen supply. A rapid heart rate decreases the time the heart is in diastole. Diastole is the only time the heart muscle receives oxygen and nutrients from the coronary arteries.24 To help patients regain homeostasis, nurses must understand the importance of returning their surgical patients to correct fluid and electrolyte balance. Patients entering the OR have a fluid WWW.ORTODAY.COM

volume deficit for a variety of reasons; their disease process, NPO status, concurrent medical conditions, and current medical therapies all contribute. During the surgery, the anesthesia provider replaces fluid IV based on patient needs. These needs differ according to the type of anesthesia, the duration of surgery, the type of surgery, and preexisting medical conditions. Inadequate fluid management can lead to changes in vital signs, such as hypotension and tachycardia, as seen in the PACU. Hypovolemia also can cause nausea, confusion, and oliguria.3 Understanding of fluid balance and related fluid management leads to positive patient outcomes. To foster positive patient outcomes, perioperative nurses must understand fluid balance and fluid management in the surgical patient. The nurse must recognize fluid volume deficit and implement evidence-based practices to maintain patient homeostasis and safety.

Debra Anscombe Wood, BSN, RN, a health writer and editor, practices in ambulatory care in Orlando, Fla.

EDITOR’S NOTE: Nancymarie Phillips, PhD, RN, RNFA, CNOR(E), a past author of this educational activity, has not had an opportunity to influence the content of this version.

Vol. 1. New York, NY: McGraw Hill; 2015: 295.

References 1. Kamat SS. Practical Applications of Intravenous Fluids in Surgical Patients. New Delhi, India: Jaypee Brothers Medical Publishers; 2013. 2. Gupta R, Gan TJ. Peri-operative fluid management to enhance recovery. Anaesthesia. 2016;71(Suppl 1):40-45. doi: 10.1111/anae.13309. 3. Phillips N. Postoperative patient care. In: Berry and Kohn’s Operating Room Technique. 13th ed. St. Louis, MO: Elsevier; 2017:585-590. 4. Whitney EN, Rolfes SR. Chapter 12: water and the body fluids. In: Understanding Nutrition. 14th ed. Stamford, CT: Cengage Learning; 2016: 372-381. 5. Brooks C. Critical care nursing in acute postoperative neurosurgical patients. Crit Care Nurse Clin North Am. 2015;27(1):33-45. doi: 10.1016/j.cnc.2014.10.002. 6. Kasper D, Fauci A, Hauser S, et al., eds. Harrison’s Principles of Internal Medicine. 19th ed. 7. Waters E, Nishinaga AK. Fluids, electrolytes, and blood component therapy. In: Nagelhout JJ, Plaus K. Nurse Anesthesia. 4th ed. St. Louis, MO: Elsevier; 2010:410-411. 8. Vincent JL, Abraham E, Moore FA, Kochanek

OnCourse Learning guarantees this educational activity is free from bias. Lisa Riedel, DNP, MS, CRNA, practices as a certified nurse anesthetist at Beaumont Dearborn Hospital and Providence Hospital in Michigan.

PM, Fink MP, eds. Textbook of Critical Care. 7th ed. Philadelphia, PA: Elsevier; 2017. 9. Understanding blood pressure readings. American Heart Association Web site. http:// www.heart.org/HEARTORG/Conditions/ HighBloodPressure/AboutHighBloodPres-

NOVEMBER 2018 | OR TODAY |

IN THE OR

continuing education sure/Understanding-Blood-Pressure-Read-

http://anesthesiology.pubs.asahq.org/article.

016-0154-3.

ings_UCM_301764_Article.jsp#.WHj5prHMxqc.

aspx?articleid=1946643. Accessed April 5, 2017.

19. Miller RD, Pardo MC. Basics of Anesthesia.

Updated January 12, 2017. Accessed April 5, 2017.

14. What to expect on the day of surgery.

6th ed. Philadelphia, PA: Elsevier; 2011:552.

10. Gong Y, McDonough CW, Padmanabhan S,

American Society of PeriAnesthesia Nurses Web

20. Singh-Radcliff N. The 5-Minute Anesthesia

Johnson JA. Chapter 32: hypertension pharma-

site. http://www.aspan.org/Resources/ASPAN-

Consult. Philadelphia, PA: Lippincott Williams &

cogenomics. In: Padmanabhan S, ed. Handbook

Patient-Information/What-to-Expect-on-the-

Wilkins; 2013.

of Pharmacogenomics and Stratified Medicine.

Day-of-Surgery. Updated July 2015. Accessed

21. Lingappan AM. Sedation. Medscape Web site.

San Diego, CA: Elsevier; 2014:747.

April 5, 2017.

http://emedicine.medscape.com/article/809993-

11. Rothrock JC. Chapter 10: postoperative pa-

15. Oliver RI. Burn resuscitation and early

overview#showall. Updated August 13, 2015.

tient care and pain management. In: Alexanderâ&#x20AC;&#x2122;s

management. Medscape Web site. http://

Accessed April 5, 2017.

Care of the Patient in Surgery. 15th ed. St. Louis,

emedicine.medscape.com/article/1277360-

22. Ackley BJ, Ladwig GB. Deficient fluid

MO: Elsevier Mosby; 2015:275.

overview#showall. Updated November 24, 2015.

volume. In: Nursing Diagnosis Handbook: An

12. Sherwood L. Venous return is enhanced by

Accessed April 5, 2017.

Evidence-Based Guide to Planning Care. 10th ed.

several extrinsic factors. In: Human Physiology:

16. Zerwekh J. Homeostasis concepts. In: Illus-

Maryland Heights, MO: Mosby Elsevier; 2014:369.

From Cells to Systems. 9th ed. Boston, MA:

trated Study Guide for the NCLEX-RN Exam. St.

23. Nettina SM. Intravenous therapy. In: Lip-

Cengage Learning; 2016:361.

Louis, MO: Elsevier; 2016:116.

pincott Manual of Nursing Practice. 10th ed.

13. Practice guidelines for preoperative fasting

17. Barash PG, Cullen BF, Stoelting RK, Cahalan

Philadelphia, PA: Lippincott William and Wilkins;

and the use of pharmacologic agents to reduce

MK, Stock MC, Ortega R, eds. Clinical Anesthesia.

2014; 83.

the risk of pulmonary aspiration: application to

7th ed. Philadelphia, PA: Lippincott Williams &

24. Kohl BA, Rosenbaum SH, eds. Anesthesia for

healthy patients undergoing elective proce-

Wilkins; 2013.

Patients Too Sick for Anesthesia: An Issue of An-

dures: a report by the American Society of

18. Voldby A, Brandstrup B. Fluid therapy in

esthesiology Clinics. Philadelphia, PA: Saunders

Anesthesiologist Task Force on Preoperative

the perioperative setting â&#x20AC;&#x201D; a clinical review. J

Elsevier; 2010.

Fasting. Anesthesiology. 1999;90(3):896-905.

Intensive Care. 2016;4:27. doi 10.1186/s40560-

Clinical VignettE For CE446 Jeff, a 52-year-old marathon runner, is diagnosed with prostate cancer. He is otherwise healthy and does not have any known allergies. Jeff is 5 feet 10 inches tall and weighs 180 pounds (81 kilograms). Previous surgeries include an appendectomy and hernia repair with no complications. Jeff has elected to undergo a robotic-assisted prostatectomy. This provides the surgeon visualization of the anatomy with minimal tissue exposure. Jeff has had nothing to drink since 10 p.m. the night before surgery. He arrives at the hospital surgical suite at 6 a.m. the morning of surgery. An IV line is started, and blood is drawn for labs. His preoperative vital signs are blood pressure 118/58 mmHg, heart rate 54 beats per minute, respiratory rate of 12 breaths per minute, O2 saturation of 100% on room air, and oral temperature 98.6 F. Laboratory values: Sodium: 142 Potassium: 4.1 Chloride: 108 CO2: 28 Glucose: 94

34 | OR TODAY | NOVEMBER 2018

BUN: 12 Creatinine: 0.82 Hemoglobin: 14.4 Hematocrit: 42 The anesthesiologist administers a light sedative and prophylactic antibiotics before transporting Jeff to the OR at 7:30 a.m. The surgery lasts six hours. Blood loss is 600 milliliters, and IV fluid replacement is 3 liters. Urine output from the Foley catheter is 350 milliliters. Vital signs remain stable throughout the procedure. On arrival to the PACU, Jeff is hypotensive with blood pressure 89/41 mmHg, heart rate 82 beats per minute, respiratory rate 18 breaths per minute, O2 saturation 97% on 2 L oxygen via nasal cannula, and oral temperature 97.4 F. Jeff is restless and reports nausea. He has not made any urine since arrival. Laboratory values: Sodium 140 Potassium: 3.7 Chloride: 102 CO2: 25 Glucose: 68 BUN 12 Creatinine: 0.82 Hemoglobin: 9.6 Hematocrit 28 WWW.ORTODAY.COM

CE446 ow much isotonic fluid should Jeff 1 H receive to replace his blood loss?

a. 300 mL b. 1,200 mL c. 1,800 mL d. 600 mL

hat is Jeff’s maintenance fluid requirement? 2 W a. 324 mL/hr b. 250 mL/hr c. 1,000 mL/hr d. 1,300 mL/hr

3 Jeff’s decrease in blood pressure

as seen in the PACU may be due to:

a. Inadequate intraoperative fluid replacement b. Pain c. Congestive heart failure d. Undiagnosed essential hypertension

hich factor contributes to Jeff’s fluid 4 W

volume deficit in the preoperative period?

a. Advanced age b. Allergic reaction to antibiotics c. NPO since midnight d. Diabetes

Clinical VignettE ANSWERS 1. Answer: C, Blood loss is replaced 3:1 with isotonic crystalloid solution, 1:1 with colloid solution, and 1:1 with replacement blood products. 2. Answer: A, The following calculation can be used to estimate maintenance fluid requirements: 4 mL/kg/ hr for the first 0 to 10 kg, 2 mL/kg/hr for the next 11 to 20 kg, 1 mL/kg/hr for weight greater than 21 kg. 3. Answer: A, One cause of hypotension in the PACU is inadequate replacement of intraoperative fluid. 4. Answer: C, Many institutions follow the NPO-after-midnight protocol. In 1999, the American Society of Anesthesiologists Task Force on Preoperative Fasting set forth a revised standard, calling for cessation of clear liquids two hours before surgery and a light meal no later than six hours before surgery. According to the society, patients may be better hydrated and have less nausea after surgery when these revised practice guidelines are followed. WWW.ORTODAY.COM

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

Deadline Courses must be completed by 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 Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider #CEP16588.

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corporate profile imp

Innovative Medical Products:

Poised for a New Era in

Customer Service

fter 35 years of providing world-class patient positioning solutions to surgical teams, Innovative Medical Products Inc.® stands primed for a new era of growth and forward focus that will ultimately bring enhanced benefits to all of IMP’s customers. Thanks to the acceptance of doctors, nurses, hospitals and surgical centers, Innovative Medical Products has been experiencing a period of sustained growth. As a result, IMP has seen significant expansion of engineering and the addition of state-of-the art machinery, to improve its product development, production and quality control. “Innovative Medical Products has had steady growth since its inception, and continuing that pattern, we are having our best year ever,” notes IMP Vice President Earl Cole. According to Cole, the recent technology investments not only affirm IMP’s solid commitment to manufacturing and engineering but also help manage IMP’s success by staying ahead of the growth curve. Cole points out that IMP’s manufacturing facility in Plainville, Connecticut, is already outfitted to add more equipment as needed. “Yet, we want our customers to

38 | OR TODAY | NOVEMBER 2018

realize we are not just a manufacturer – though an excellent one at that – but also a medical innovation company that has invented positioning solutions that have become the gold standard in their respective surgical specialties,” says Cole. “We are a strong, vibrant company because we have innovative products

De Mayo Hip Positioner® |

that effectively serve a very important medical niche and we are dominant players in that market.” Of course, IMP’s recent advancements in the latest manufacturing technologies and its continuous development of new, innovative, patient positioning solutions doesn’t happen

The Dr. Edward De Mayo/Innovative Medical Products partnership

has produced a number of ground-breaking orthopedic solutions since 2001, including the Large De Mayo Hip Positioner® that stabilizes obese patients during surgery.

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corporate profile imp

A team of IMP engineers is leveraging major new technology and equipment investments to efficiently design, test and manufacture medical products that lead the industry in usability, quality and cost-effective performance.

automatically. Rather, Innovative Medical Products’ success depends on a wide range of factors to produce unrivaled positioning solutions that are truly at the world-class level; including:

A focused vision and unwavering mission Since its establishment in 1983, Innovative Medical Products has been focused on developing and marketing innovative products to benefit and improve efficiency in the operating room and hospital clinics where patient stability and positioning are required. IMP’s primary focus is orthopedics, anesthesiology, and nursing support. Its products are designed to provide accuracy for the surgeon, save time for OR personnel, and benefit the overall patient surgical experience. “When patient care is the first priority, everyone benefits. That is and will always be the main mission of Innovative Medical Products,” says IMP President Jim Bailey.

Close collaboration with orthopedic surgeons In addition to its own research and development successes, advancements WWW.ORTODAY.COM

in minimally invasive surgical procedures (MIS) and navigation through computer-assisted orthopedic surgery (CAOS) have also brought about IMP’s innovative partnerships with world-renowned surgeons committed to improving patient outcomes and surgical techniques. IMP began working closely with orthopedic surgeons in 1984 to develop patient positioners that were specific solutions to surgeon and operating room staff needs. Early collaborators included Dr. George McGuire, Green Bay, Wisconsin; Dr. William Capello, orthopedic surgeon, Indianapolis, Indiana; Dr. G. David Ritland, Hartford, Connecticut; and Dr. Steven Haas, New York, New York. In 2001, IMP began its current relationship with Dr. Edward De Mayo, an orthopedic surgeon in San Francisco. Like some other orthopedic surgeons, Dr. De Mayo has a creative mind having designed things throughout his life, which helped him create devices to improve outcomes with orthopedic surgery. The

“ When patient care is the first priority, everyone benefits. That is and will always be the main mission of Innovative Medical Products.

”

– IMP President Jim Bailey

De Mayo-IMP partnership has resulted in a number of innovative orthopedic solutions including the De Mayo Hip Positioner®, De Mayo Universal Distractor®, De Mayo Knee Positioner®, De Mayo Ankle Distractor™ and the De Mayo RoTractor®. IMP has also collaborated with Dr. Alan Reznik, of the Orthopaedic Group, New Haven, Connecticut, on the Reznik Universal Shoulder Positioner®; and Dr. Frank Humbles, NOVEMBER 2018 | OR TODAY |

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corporate profile imp

Conway, South Carolina, on the Humbles LapWrap®. Besides its close collaboration with distinguished orthopedic surgeons, IMP itself has acquired more than 20 patents over its 35-year history, with multiple, additional patents pending. Renowned teaching hospitals specify IMP positioners and protective pads owing to their reputation and success. World-famous orthopedic companies have also relied on IMP’s high-quality and innovative devices to aid in their advancements in robotics, computer-assisted surgeries, and improved surgical techniques that enhance procedure performance, while reducing costs to hospitals and improving patient outcomes.

Always remembering it’s a team effort While CEO Alan A. Wasley credits IMP’s resiliency to product innovation and ingenuity, niche market targeting and the company’s ability to form productive alliances with economic growth agencies, he points out that, besides its 50-plus employees at the company’s corporate headquarters in Plainville, Connecticut, IMP depends on and shares its success with, a whole array of distributorships, sales reps, marketing personnel, financial professionals and other partners. “These

folks make up a cadre of nearly another 200 to 300 people, who are intricately involved with and a real, integral part of our company,” Wasley points out. “We couldn’t be where we are today without the expertise, experience and loyalty of our wonderful workforce and staff and our superb support network.”

Looking ahead The growth and success of Innovative Medical Products has been built on a tradition of manufacturing the best quality, Made-in-America, products, supported by an unflagging resolve to change with the times and adapt to new technologies. Since its beginning in 1984, IMP has pioneered many advances in orthopedic and surgical positioning and has become a world leader in patient positioning devices. This ability to seize opportunities, chart new courses and wholeheartedly commit its resources to serving its customers’ needs are the secret of its success – something that has kept IMP in business for more than 35 years and will continue to do so well into the future. For more information, visit impmedical.com

Reznik Universal Shoulder Positioner™ | In collaboration with Dr. Alan Reznik, of the Orthopaedic Group in New Haven, Conn., Innovative Medical Products developed the Reznik Universal Shoulder Positioner™, providing surgeons three planes of adjustment when performing arthroscopic shoulder surgeries.

40 | OR TODAY | NOVEMBER 2018

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The complete positioner…. for small to obese

Discover the De Mayo Hip Positioner Systems The hip positioner you can customize for any patient ®

Stop breaking your back positioning patients. Now there’s a simple, adjustable positioning alternative for any OR table. The doctor-designed De Mayo Hip Positioner is a complete system that gives you everything you need to secure any patient – obese or small – with unobstructed access to the surgical site. Latex-free, single-use Patient Protective Pads provide superior protection and added stability to the overall construct. Move up to the positioning alternative that’s better for every body. Visit www.impmedical.com or call 800-467-4944 to order your complete system today. ®

The operative word in patient positioning.

The smarter positioner you build around your patient Secure obese patients without lifting

Foam pads protect patients securely

Security without abdominal pressure

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r bnu lol yui nt g AND

“These disruptive behaviors have the industry and all of its s ta k e h o l d e r s o n h i g h a l e r t. ”

By Don Sadler

Among perioperative nurses, they are sometimes referred to as the “killer B’s”: burnout and bullying. Both of these B’s have resulted in added stress, job frustration, dissatisfaction and sleepless nights for many OR nurses. In fact, bullying and burnout are inextricably linked – because bullying can be a major factor leading to burnout. Given this, it’s critical that health care organizations and nurse managers do everything they can to reduce instances of bullying in order to help reduce levels of burnout among OR nurses.

O R B u l ly i n g i s C o m m o n The statistics with regard to bullying in the OR are not encouraging. According to a study conducted by the Association of periOperative Registered Nurses (AORN), about six out of 10 (59 percent) perioperative nurses and surgical technicians said they had witnessed coworker bullying on a weekly basis. Also, more than three out of 10 (34 percent) OR nurses in the survey said they had witnessed at least two bullying acts per week. In a survey conducted by employment agency RNnetwork, nearly half (45 percent) of nurses said they have been verbally harassed or bullied by other nurses. Also, 41 percent said they’ve been verbally harassed or bullied by managers or administrators and 38 percent said they’ve been verbally harassed or bullied by physicians. According to Ellen Fink-Samnick, MSW, ACSW,

Burnout LCSW, CCM, CRP, the literature is consistent that health care organizations experience among the highest incidences of workplace bullying of any employment sector. “These disruptive behaviors have the industry and all of its stakeholders on high alert,” Fink-Samnick says. The Joint Commission has identified bullying as a Sentinel Event. It defines bullying as intimidating and disruptive behaviors that include “overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.” The Workplace Bullying Institute defines bullying as “the repeated, health-harming mistreatment of one or more persons (or targets) by one or more perpetrators.” Bullying behavior is marked by abusive conduct that is threatening, humiliating or

The Pecking Order of B u l ly i n g Fink-Samnick says that many experts view bullying in the OR as a direct reflection of the power that stems from the traditional hierarchical stratification that is a hallmark of many health care organizations. “The individuals at the top of the hierarchy – like c-suite and department leaders and surgeons – have the power to bully those below them solely by virtue of their position,” she says. Some researchers believe that good old-fashioned competition tends to pit nurses against each other and lead to bullying. Their theory is that competition among mostly female nurses has shifted from attracting a man to achieving status and respect in their job as perioperative nurses. Adds Fink-Samnick: “Most nurses can share at least one story reflecting the well-known stereotype that

and disruptive behaviors associated with bullying fuel medical errors and lead to preventable adverse outcomes.” For example, more than 75 percent of disruptive behaviors lead to medical errors, she says, while 30 percent of disruptive behaviors lead to patient deaths.

Factors Leading to Burnout There are many factors that can lead to burnout among OR nurses, with bullying being just one of them. High stress, long shifts and physical exhaustion can also lead nurses to the point of what Beth Genly MSN, the co-author of “Save Yourself From Burnout: A System to Get Your Life Back,” calls “souldeep exhaustion.” “Burnout among OR nurses can lead to withdrawal from work and life, as well as deep doubts about one’s ability to make a difference,” adds Genly. “It typically has three

“t oB uwr i nt oh ud tr aawm ao ln gf rO oR m n wu ro sreks acnadn lli ef ea ,d a s well as deep doubts about one’s ability to make a difference. intimidating or leads to interference that prevents work from getting done. Bullying behavior in the OR can be overt – like threats, physical violence or verbal harassment – or more subtle. Sometimes referred to as “incivility,” subtle harassment includes things like sabotage, exclusion, unequal treatment, unfair assignments and withholding information.

46 | OR TODAY | NOVEMBER 2018

”

they ‘eat their young.’ ” A study conducted by the Robert Wood Johnson Foundation determined that younger OR nurses are especially susceptible to being bullied by older and more experienced colleagues. “Bullying in the OR grossly impacts patient quality and safety and traumatizes the workforce,” says Fink-Samnick. “The intimidating

– BETH Genly

dimensions: emotional fatigue, cynicism and inefficacy.” According to Erin Kyle, DNP, RN, CNOR, NEA-BC, Perioperative Practice Specialist with AORN, researchers have found relatively high rates of burnout syndrome among OR nurses. “In the 2017 AORN Salary Survey, the vast majority of OR nurses who are planning to leave health WWW.ORTODAY.COM

AND

bullying

care cited dissatisfaction with their work environment or culture,” says Kyle. “While this survey didn’t address burnout explicitly, some conclusions may be drawn from this response data about burnout.” Kyle says there are both intrinsic and extrinsic factors that influence burnout among OR nurses. She identifies five intrinsic personality factors that place nurses at increased risk for burnout: neuroticism, agreeableness, conscientiousness, extraversion and openness to experience. “Perioperative nurses who have personality traits that make them more susceptible to burnout are at increased risk to experience it when they are faced with extrinsic factors,” says Kyle. Extrinsic factors include things like the fast pace of the OR environment, minimal rest between on-call, moral dilemmas and ethical issues, and a harsh work culture. There are several burnout risk factors that are unique to perioperative nursing, Kyle adds. “One is the fact that perioperative nurses are largely unknown to patients and their families because they are hidden behind the ‘double doors’ leading into the operating room.” “Another is the increasing demands presented by rapid technology advances,” she adds. “OR nurses are expected to have a vast knowledge base, be extraordinarily flexible and adaptive to change, and be critical thinkers,” says Kyle. “They’re also expected to balance what they see as the best care for patients with organizational demands to contain costs." “Over time, these pressures combined can drive excellent perioperative nurses into distress and eventually burnout,” Kyle concludes.

Five Areas of Focus Genly has identified five specific WWW.ORTODAY.COM

areas where OR nurses should focus their efforts to avoid burnout: 1. Self-care: This is about whether you are taking care of the basic functions that keep your body going. “Self-care includes eating, sleeping, hydration and elimination – all of the functions that become troublesome if they are regularly interrupted or ignored,” says Genly. 2. Reflection and recognition: “This looks at your level of awareness of your own feelings and values, whether the people around you recognize your accomplishments, and whether you allow yourself to observe things for what they are,” says Genly. 3. Capacity: This has to do with how much stress you can take and your awareness of how close you are to this limit. “In other words, have you spread yourself too thin?” says Genly. “And if you have, are you aware of it?” 4. Community: This reflects the social elements in your life. “Do you feel connected with a community of people who share your values and have good intentions for your wellbeing?” says Genly. “If you do, are you having enough interaction with them?” 5. Coping skills: This looks at what types of coping methods you tend to use and whether they are helping or hurting you. “Included here are elements of how you actively deal with stress, as well as unconscious habits that you may not realize are types of coping methods,” says Genly.

entire perioperative team,” says Kyle. “Health care organizations are responsible for cultivating a work environment that is supportive of perioperative nurses and other health care professionals.”

Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP

A Shared Responsibility Kyle says that OR nurses and health care organizations share responsibility for recognizing the risks of burnout and helping reduce this risk. “Cultural problems like pervasive bullying sometimes exist in the perioperative setting that can affect not just one nurse, but the

Erin Kyle

DNP, RN, CNOR, NEA-BC

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Jackie Patterson SPOTLIGHT ON

BY MATT SKOUFALOS

BSN, CCRN, FNE-SA

In the course of a lifetime, every career path has twists and turns, but to Jackie Patterson, nursing is a field in which “you kind of end up falling into things.” Prior to joining the cardiothoracic recovery unit at Our Lady of Lourdes Hospital in Camden, New Jersey, Patterson lived several professional lives. But since beginning there, she’s also passed up different opportunities to leave. She takes it as a sign that she’s in the right place. It’s a lesson she learned early in life. Patterson earned a bachelor’s degree in fine art at the University of the Arts in Philadelphia, Pennsylvania, and subsequently took a job as a ceramic studio technician at the University of Pennsylvania. The realities of 16-hour workdays – that left no time for her own creations and concerns about the ill health of her mother-in-law – soon heralded a career change. “She would tell me that the nurse would leave a big fingerprint on her day; that she would have a good or bad day based on which nurse she had,” Patterson said. “That always stuck with me.” Patterson decided to advance her education as a result, and enrolled in

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an accelerated bachelor’s program at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania. She completed it in 13 months, and “knew right away that nursing was the right thing.” Upon graduation from nursing school, she took a night shift position on the telemetry floor of Kennedy Health in Washington Township, New Jersey. She knew it would be a stepping-stone to the next stage of her career and recalls that “it was very hard work.” “There are nurses that make a career out of doing that type of floor nursing, and they were amazing,” she said. “They saw new nurses day after day, they precepted them, turned them into amazing nurses, saw them leave, and the new nurses come in.” “I have a lot of respect for nurses who make a career out of floor nursing,” Patterson said. “Not many do. It’s physically hard. You have to be on your toes. Once you finish making the rounds, you’re making them again.” Keeping on her toes was also a problem when night shift ended, leaving Patterson to join highway rush-hour traffic for her commute home. She remembers the toll of exhaustion setting in, and contriving various ways to fight

nodding off behind the wheel – putting the windows down, blasting the radio, talking to someone on the phone. They didn’t help much. “I’d be literally falling asleep singing,” Patterson said. “I couldn’t do it anymore. Luckily, I found a job at Lourdes [Health System], and I loved it right away.” A friend invited Patterson to join her in the cardiac ICU at Lourdes for an assignment that was five minutes from her home. Eventually, she switched to the cardiothoracic recovery wing there, and she’s remained since. She cites its camaraderie, the responsiveness of colleagues, and autonomy of the work environment as key factors in remaining – that, and the opportunity to see patients recover, which wasn’t always present in her prior assignments. “In a lot of ICUs, you see the same people over and over, and you send them home sick, and you know they’re coming back,” she said. “Where I am now, they come in sick, and you send them home healthy, and they’re going back to what they need to be doing.” “You don’t get to follow up very often,” Patterson said. “But if you do connect with someone, it’s rewarding.

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Jackie Patterson enjoys working close to home and spending free time with her family.

You really do see people on the brink of death.” Patterson’s unit is “nurse-driven,” she said, which makes a big difference in her outlook. Preset protocols for communication with doctors and physicians’ assistants allow for smooth workflow, and when nurses see changes in their patients, the doctors take them seriously, Patterson said. “It’s definitely a family,” she said. “Nurses have left and come back because of how we are. I’ve had other opportunities open up for me, and I can’t leave because I love it so much.” Some opportunities haven’t required Patterson to forsake her post at Lourdes, including training as a forensic nurse examiner. After a lengthy certification process, she became available to work as an independent examiner through the Camden County Prosecutor’s Office of New Jersey. That meant on-call and overnight availability to respond to sexual assault cases at any of five hospitals within the county. The work, like her assignment in the cardiac ward, “was pretty intense,” Patterson said.

“YOU SEE SOMEONE IN THEIR DARKEST MOMENT, AND YOU DO WHATEVER YOU CAN TO EASE THAT.” “You see someone in their darkest moment, and you do whatever you can to ease that,” she said. “I did not do that for very long, although I do still carry the certification. It’s a tough gig.” WWW.ORTODAY.COM

“You’re going to see people from all different walks of life,” Patterson said. “I would see college students, homeless drug addicts; I’d get called in for kids. You really see every type of person.” But once called in, Patterson performed the work for which she’d been trained: conducting intimate physical examinations from emotionally vulnerable patients, witnessing their injuries, and collecting their stories. “You do a physical exam, and you document everything,” she said. “You collect this kit, and it had to be done soon, and in a way that you wouldn’t contaminate any specimens. The entire time you’re doing it, you’re communicating with the patient, making sure they know what you’re doing, that they’re aware, that they’re comfortable.” “You know that they don’t want to be there,” she said. “You kind of don’t want to be there. But someone’s got to do it, and in the end you hope that you’re giving them justice.” In one of the hardest cases she was called to investigate, Patterson eventually learned that her diligence led to the maximum sentence for an assailant who was found guilty in court. “That was very rewarding,” she said. “Pretty amazing.” Into whatever environment she’s been thrust, Patterson said she’s managed to thrive because she knows that she’s got options. With so many different specialties available to nurses, she knows that her career can adapt as her life circumstances or personal preferences shift. The knowledge of that freedom has given her the willingness to stay put. “If you don’t like what you’re doing, there are so many different options,” Patterson said. “If you’re miserable at your job, other people can see that as well, so you should probably do something different. Or go back to school, use your degree, and do something that suits you better.” NOVEMBER 2018 | OR TODAY |

OUT OF THE OR fitness

6 Ways to Wake Up at Work By Marilynn preston hy are Americans gaining so much weight? If we were beach balls, two-thirds of us would have exploded by now. Obesity is an epidemic, a national health problem of massive proportions and ever expanding waistlines.

But why? There have been very few (sorry, but I can’t resist) large-scale studies. Obesity experts offer up many tantalizing theories – too little exercise, too much time on our screens, useless fad diets, scam diet drugs – but very little in terms of data-based facts, a term that used to mean something. This we know: You can’t outrun your fork. Food consumption is the primary suspect when it comes to the exploding body problem. Americans eat too much of the wrong stuff – processed foods high in sugar and naughty additives that muck up our metabolism and leave us hopelessly addicted to eating more and more. But food is only part of the problem. There is a surprising link between the fat we are and the jobs we do. Research led by Dr. Timothy Church, an exercise researcher at the Pennington Biomedical Research

52 | OR TODAY | NOVEMBER 2018

Center in Baton Rouge, Louisiana, showed that a major reason Americans are packing on the pounds is we are significantly less active in the workplace than we used to be. In 1960, about 50 percent of workers did jobs that required moderate physical activity every day. Now, almost 60 years later, many of those lift-and-carry manufacturing and agricultural jobs have gone byebye, and only about 20 percent of the labor force is engaged in physically active jobs. The rest of us – 80 percent! – are doing sedentary work that requires little more than sitting, clicking and checking messages. As a result, we’re burning, on average, 120 to 140 fewer calories every day. Day after day after day. And that, according to Church, coincides in a very significant way with the weight gain we are seeing in so many Americans. If you suspect your job is making you fatter than you want to be, here are some strategies to help you reverse that uncomfortable slide into tighter jeans:

Reframe fitness Stop thinking of fitness as something you do before your

job or after you come home. If you want a slimmer body – and more focus – incorporate healthier choices into your workday. You know these tips by heart: Snack on fresh fruit instead of M&M’s; take the stairs instead of the elevator; do some walking as part of your lunch break. Turning a tip into an action plan is the real work ahead of you. Are you ready?

Explore what’s possible Many enlightened companies have invested in wellness programs that include on-site gyms, healthier food choices in vending machines, meditation rooms and more. What does your company offer? Will it subsidize a health club membership? Host yoga classes at noon? If programs exist, take advantage of them. If they don’t, make polite inquiries, and join up with some health-conscious colleagues to get something started.

Reboot your commute If you drive to work now, park in a spot that is a 10- or 15-minute walk away. Can you bike all or part of the way, perhaps using a bike carrier on your car? Many city buses carry bikes. Ditto some commuter trains. WWW.ORTODAY.COM

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Be inventive. Be bold. Be more responsible for your own health and creative solutions will appear.

Stand up for yourself I’m over-the-top when it comes to praising the virtues of a standing desk. Can you buy one, rig one, beg for one at work? More than 10,000 studies show all the bad stuff that happens when you sit too much. If your employer won’t pay for one, save up and get one anyway. It’s that important.

Reconsider your workspace Abandon your office chair and sit on an inflatable ball, to build core strength and balance. Take stretching breaks every hour or so, to improve flexibility and counter fatigue. Keep light weights under your desk, and do a 10-minute routine to strengthen your arms and shoulders. When you feel stress and tension, hide somewhere to do a short calming meditation.

Keep a journal

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OUT OF THE OR health

What Kinds of Exercise are Good By Joyce Gomes-Osman, Ph.D., P.T. y interest in reaping the brain health benefits of exercise comes not only from my work as a physical therapist and researcher in this field, but is also driven from a very personal place that unfortunately many of us have witnessed or will witness in our lifetime: a family member with disabling memory loss. In my case, it was seeing the crippling effects Alzheimer’s disease had on my grandfather, who passed away from complications related to his condition not so long ago.

What do we know about exercise and brain health? As of today we know: 1) adults 65 and older are the fastest growing demographic group, reaching 20 percent of the world population by 2030; and 2) maintaining a sharp mind is a top priority for them. The idea that a healthy mind lives in a healthy body dates back at least 2,000 years, and the benefits of exercise beyond physical health is not a new idea either. The New England Journal of Medicine said this in 1887: Exercise sustains and improves

54 | OR TODAY | NOVEMBER 2018

for Brain Health?

bodily health by expanding the lungs, quickening the circulation, and promoting growth in muscles and bones. But we know that besides doing all these things, exercise may be made to contribute to brain growth and to the symmetrical development of the mental faculties. The key question that remains unanswered 130 years since that NEJM article is: what type of exercise should we do, and how much of it is needed to specifically target brain health? What is the ideal exercise for brain health? The verdict is still out on an ideal exercise “dose” for brain health, because in short, it’s complicated. The long answer is that we are still learning about all the ways in which exercise changes our biology, since not all exercise is created equal, and of course it ultimately depends on who we are, for we are all different. The best exercise program for one person may be quite different from the best one for another. A wealth of studies both in humans and animals have linked the cognitive improvements following exercise (mainly aerobic, such as running and cycling) to the increased capacity of the heart,

lungs, and blood to transport oxygen. As a result, generalized brain effects, such as a boost in the number of blood vessels and synapses, increasing brain volume, and decreasing age-related brain atrophy, have all been reported. Aside from this, more localized effects in brain areas related to thinking and problem solving have also been reported, such as a boost in the number of new nerve cells and increases in proteins that help these neurons survive and thrive. On the other hand, in recent years cognitive improvements have also been demonstrated with other forms of exercise, such as low-intensity mind-body exercises (think some forms of yoga and tai chi) and resistance (i.e., weight) training. Because these exercises either do not work the heart as hard, or do so in a different way, we know less about exactly how they promote these cognitive changes. However, I see this as an encouraging finding for two reasons. First, some sedentary people may need to start with a more gentle routine, eventually building up to more vigorous exercise practices; and second, many people already engage in resistance training for other reasons, such as building stronger muscles and bones. WWW.ORTODAY.COM

OUT OF THE OR health

What can I do now? The reality is that less than 40 percent of adults 65 and older engage in at least 150 minutes of physical activity per week, and 20 percent don’t do any type of formal exercise. While these recommendations were drafted by the Centers for Disease Control and Prevention for physical health (and are not brain health-specific), a target of 30 daily minutes, five days a week is a reasonable goal, guaranteed to promote physical health. However, we don’t yet know if this is the correct dose for brain health. So in the meantime, it seems that since aerobic exercise, resistance training, and mind-body exercises are all associated with evidence specifically supporting benefits for brain health, you should maintain a diverse practice, using these exercises as the building blocks of your regimen.

And where is the science on exercise and brain health headed? I am confident that through research we will learn the optimal dose of exercise to maintain our brain health, but as of now my educated guess is that the answer won’t be a one-size-fits-all “prescription.” I also hope that we will discover the answers to many other incredibly intriguing questions related to physical activity and cognitive health, such as: What are the exercises that people will do, and do these lead to any cognitive benefit, on an individual level?

– Joyce Gomes-Osman, Ph.D., P.T., is a contributor to Harvard Health Publications. SOURCE: Harvard Health Letters

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OUT OF THE OR nutrition

Are Colorful, Segmented By Joy Stephenson-Laws, JD, Founder ccording to a recent survey, many American children go days without eating a single vegetable! And sadly, statistics show that bad eating habits are affecting our children’s health.

The incidence of children with obesity in the United States has more than tripled since the 1970s, according to the Centers for Disease Control and Prevention (CDC). Currently, about one in five schoolaged children (ages 6-19) are obese. In addition, “about one-third of American youth are overweight, a problem closely related to the increase in kids with type 2 diabetes, some as young as 10 years old,” the CDC reports. And the longer children are obese or overweight, the more likely they are to remain so as adults. Kids may be picky eaters, often turning their noses up at the steamed broccoli you put on their dinner plates. Eating plenty of fresh fruits and vegetables is critical to the health of our children. And the earlier they develop good eating habits, the better. We have previously discussed that children who eat poorly (for example, too much sugar or salt) are more likely to eat

56 | OR TODAY | NOVEMBER 2018

Plates the Secret? poorly as adults. Now, a new study suggests that the kind of plate you use may play a key role in getting your kids to eat healthier foods. The study found that preschool children ate more vegetables when given segmented plates with pictures of fruits and vegetables on the plates. Researchers measured the amount of fruits and vegetables consumed by 235 preschool children. School meals were served family style, meaning that large, communal servings were given to each table and kids were able to serve themselves. Initially, the children were given just plain white plates to eat their food. Four weeks later, the children were then given segmented plates with pictures of fruits and vegetables. (You can purchase plates like these online.) The results? “In comparing the amounts of fruits and vegetables used, the researchers found that the children dished themselves on average 13.82 grams more vegetables when using the segmented plates compared to the plain white ones,” according to the report. They also ate on average 7.54 grams more vegetables when using the seg-

mented plates. They also report that the children ate slightly more fruit as well, but the difference was not considered to be statistically significant. What I find particularly exciting about this study is that kids actually served themselves more vegetables. It just goes to show you that children are more than capable of making smart food choices if we provide them with the necessary knowledge and tools. How else can you get your child to eat more veggies and other healthy foods? • Meal prep. Credible research has shown that kids who are involved in the meal preparation process at home are more likely to make better food choices outside of the home. Kids who meal prep may also be more likely to enjoy a wider variety of fruits and vegetables. • Add flavor. You don’t need tons of butter and oil to make vegetables suitable for your child’s picky taste buds. Research has shown that using herbs and spices, like cumin, ginger and black pepper, to flavor veggies may make children eat more veggies. • Take it to the farm. Another way to encourage your kid to eat healthy is WWW.ORTODAY.COM

OUT OF THE OR nutrition

•

by taking him or her to your local farmers’ market. Seeing the array of colorful, fresh produce and learning about where these foods come from can be empowering. Instead of seeing fruits and vegetables as foods they have to eat, they may see them as foods they want to eat. Take it to the garden. One study suggests that if kids grow their own vegetables, they are more likely to eat them. So if you have a garden at home, have your kid help you out with the gardening. Again, doing activities like this may be empowering to your child and encourage healthy eating. Don’t forget water. Water is a very important nutrient that their bodies need to remain healthy. (The other five nutrients are protein, fat, carbohydrates, minerals and vitamins). Research has shown that kids who drink more water have a lower intake of sugar and saturated fat. Be sneaky. Of course, you want your children to love the taste of kale, but some kids (and adults!) just may not like the taste of it and other leafy greens. The good news is you can mask greens in fruit smoothies. Try giving your child this Tropical Green Smoothie: Just toss in your blender: • Kale or spinach

• Mango • Strawberries • Orange juice • Milk I sometimes add some fresh parsley, which is very nutrientdense, to my fruit smoothies. You won’t even know it’s there! And finally, I highly recommend having your child take a nutrient test. Many of us have nutrient deficiencies and imbalances but don’t even know it. The earlier you can pinpoint your child’s exact nutritional needs, the better. If your child does have any imbalances or deficiencies, you can work with a competent health care professional to possibly tweak your child’s diet and/or have him or her take quality supplements. Let’s help our kids enjoy their healthiest lives! – Joy Stephenson-Laws is the founder of Proactive Health Labs (pH), a health care company that provides tools needed to achieve optimal health. The pH professional health care team includes recognized experts from a variety of health care and related disciplines, including physicians, health care attorneys, nutritionists, nurses and certified fitness instructors.

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OUT OF THE OR recipe

Roast Herbed Chicken with Caramelized Garlic, Dates, Lemon and Olives

Recipe

INGREDIENTS:

the

58 | OR TODAY | NOVEMBER 2018

• 25 peeled medium whole garlic cloves, ends cut off • 1 tablespoon finely chopped lemon zest • 1/3 cup fresh lemon juice • 2 tablespoons olive oil • 1/4 cup plus 2 tablespoons finely chopped fresh herbs (any combination of rosemary, thyme, parsley, basil and oregano) • • • •

• •

Salt Freshly ground black pepper 1 teaspoon sumac, optional 1 3 1/2- to 4-pound chicken, cut up or 4 chicken breast halves and 4 thighs 1 lemon, thinly sliced 8 fresh Medjool dates, pitted and cut into fourths for a total of 32 pieces 3/4 cup chicken stock 1/3 cup pitted green olives or black

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 Awardwinning radio show host. You can contact her at www.seriouslysimple.com.

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OUT OF THE OR recipe

Enjoy Salty Flavors and a Sweet Finish T

he following recipe for roast lemon chicken, which also includes sweet Medjool dates, is a treasured family favorite that is the centerpiece of our holiday table. However, it is a dish that is great anytime of year. Traditional roast chicken with olives, garlic and lemon is a Moroccan specialty. Here you donâ&#x20AC;&#x2122;t need a tagine (a special clay roasting pot with a conical top) to achieve tasty results. Finding already-peeled garlic cloves at your market makes it a snap to put this together. I blanch the garlic cloves first to help the garlic cook through evenly. If your garlic cloves are too large, slice them in half so that the garlic cooks uniformly. Donâ&#x20AC;&#x2122;t be put off by the large number of garlic cloves â&#x20AC;&#x201C; they add a wonderful nutty, richness to the sauce.

Cook the chicken in a shallow roasting pan that can be brought to the table for a casual presentation. Use a microplaner or grater to grate the lemon zest before squeezing the juice. The lemon slices and optional sumac add a fruity touch. Ground sumac is a versatile spice with a tangy lemony flavor, but it is more balanced and less tart than lemon juice. Fresh Medjool dates are my pick here for their intense, rich, caramel-like flavor and soft, chewy texture. The dates add a sweet balance to the tart lemon and salty olives. You can easily double or triple this recipe, making sure to use enough pans so as not to crowd the chicken. Serve with roasted vegetables or a vegetable rice pilaf for a hearty and satisfying festive meal.

Roast Herbed Chicken with Caramelized Garlic, Dates, Lemon and Olives Serves 4 1.

Place the garlic cloves in a medium saucepan of boiling water. Blanch the garlic for 5 minutes or until very slightly softened. Drain and set aside. 2. Combine the zest, lemon juice, olive oil, 1/4 cup herbs, salt, pepper and sumac, if using, in a small bowl. Mix to combine. 3. Preheat the oven to 425 F. Arrange the chicken pieces in a roasting pan, skin side up, and pour over the lemon herb mixture. Arrange the garlic cloves, lemon slices and dates all around the chicken, moving them to coat with the mixture. Roast for about 40 minutes or until the chicken pieces are nicely browned and no pink color remains. (The dark meat may need another 5 or 10 minutes to finish cooking.) 4. Remove pan from oven. With potholders place pan on top of the stove on medium-high heat, add the stock and deglaze the pan by scraping up any of the brown bits on the bottom of the pan. Sprinkle on the olives, and toss them around to heat through. Garnish with remaining 2 tablespoons of herbs and serve right from the pan or transfer to a platter and serve immediately. NOTE: The lemon-herb mixture can be made 4 hours ahead, covered and kept at room temperature.

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NOVEMBER 2018 | OR TODAY |

OUT OF THE OR pinboard

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The News and Photos

that Caught Our Eye This Month AVOID ADDED SUGARS

Here are ways for parents to become savvy about the sneaky ways food companies add sugar to foods:

CONFUSING FOOD LABELS Figuring out how many added teaspoons are in a recipe is not straightforward. First, food labels report sugar in grams. So remember this equation sk 10 parents how much added the next time you look at a label: 4 sugar their child consumes each grams of sugar = 1 teaspoon of sugar. day and there’s a good chance that To further complicate things, food at least 9 of them will have no clue or labels historically did not break down will underestimate it. In fact, research published in the International Journal of added sugar with naturally occurring Obesity reported that 92 percent of the sugar. So when we look at a label on a sweetened fruit yogurt, it’s often parents surveyed in the study underunclear how much of the sugar comes estimated the added sugar content in from natural milk sugars and fruit foods and beverages. The study also versus how much extra sugar the food showed that kids are more likely to be overweight when their parents are mis- company has added. Luckily, by the informed about sugar in their kids’ diet. end of 2018 most food labels will be Since sugar intake is associated with an updated to break down total vs. added sugar which will make reading a label increased risk of being overweight and more straightforward. parents are a child’s nutritional gatekeeper, it essential that they know the SMALL PORTION SIZES ins and outs of sugar. A favorite food may not look like it has much sugar per serving, but if you look closely you may notice that the serving size is much smaller than what you may actually eat.

OUT OF THE OR pinboard

SWEETENING WITH “HEALTHIER” SUGARS Sweeteners like honey, agave and maple syrup may make a food appear healthier, but that doesn’t mean they actually are. While they may be more natural than refined sugar, manufacturers are still adding sugar to a food that may not need extra sweetness. USING SNEAKY NAMES FOR SUGAR Sometime it can be hard to spot sugar in an ingredient list because there are so many code names. One nutrition source reports that sugar can be spotted with as many as 61 different names. Sugar’s many code names include: rice syrup, dextrose, maltose and barley malt, and high-fructose corn syrup. KNOW THE SNEAKIEST FOODS There are some foods that seem to have hidden sugars in them more often than others. Be aware of and read the labels carefully on such foods as granola bars, breakfast cereals, yogurt, fruit snacks and juice. – Dr. Nimali Fernando if the founder of The Doctor Yum Project. To learn more, visit the site at: www.doctoryum.org.

CAUSES OF MOOD SWINGS You undoubtedly have some days when you’re in a better mood than others. On the bad days, you’re sad and grumpy and just want to be left alone. The next day, you’re content and happy, like you’re walking on sunshine. And sometimes, you feel those range of emotions all in the same day. It feels like you’re riding an emotional rollercoaster at times. As long as these mood swings don’t disrupt your life or the lives of those around you, these ups and downs are considered normal. But if your moods swings are frequent and serious, speak with your health care provider. You can discuss possible reasons and find out if you have a medical condition that’s caus-

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ing those mood swings. Then, you can get appropriate treatment. You may need to get therapy or take medications. You may have to make lifestyle changes like getting plenty of exercise and sleeping and eating healthfully. Here are some possible reasons behind what may be causing your bumpy ride: • You’re going through hormonal changes • You’re stressed • You have a mental health condition. For more information, visit HealthyWomen.org.

NOVEMBER 2018 | OR TODAY |

INDEX

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Healthmark Industries Company, Inc.…………… 4

Mobile Instrument Service & Repair……………… 6

AIV Inc.…………………………………………………………………15

Innovative Medical Products…………… 38-41, BC

Pacific Medical………………………………………………… 55

Alco Sales Service, Co.…………………………………… 57

Jet Medical Electronics Inc…………………………… 53

Paragon Services……………………………………………… 37

AORN………………………………………………………………… 63

MAC Medical, Inc……………………………………………… 49

PRN/ Physician's Resource Network…………… 53

C Change Surgical………………………………………………13

MD Technologies inc.……………………………………… 42

Ruhof Corporation……………………………………………2, 3

Case Medical, Inc.…………………………………………… 43

Medline………………………………………………………… 20-21

TBJ Incorporated………………………………………………… 5

Cygnus Medical…………………………………………………… 9

MedWrench……………………………………………………… 42

TIDI……………………………………………………………………17, 19

Doctors Depot………………………………………………… 48

Microsystems…………………………………………………… 36

TRU-D………………………………………………………………… 22

ANESTHESIA

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REPAIR SERVICES

Doctors Depot………………………………………………… 48 Paragon Services……………………………………………… 37

AIV Inc.…………………………………………………………………15

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Alco Sales Service, Co.…………………………………… 57

Cygnus Medical…………………………………………………… 9 Doctors Depot………………………………………………… 48 Jet Medical Electronics Inc…………………………… 53 Mobile Instrument Service & Repair……………… 6 Pacific Medical………………………………………………… 55

categorical

Microsystems…………………………………………………… 36

ASSOCIATION AORN………………………………………………………………… 63

BIOMEDICAL PRN/ Physician's Resource Network…………… 53

CARDIAC PRODUCTS C Change Surgical………………………………………………13 Jet Medical Electronics Inc…………………………… 53

CARTS/CABINETS Alco Sales Service, Co.…………………………………… 57 Case Medical, Inc.…………………………………………… 43 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…………… 4 MAC Medical, Inc……………………………………………… 49 TBJ Incorporated………………………………………………… 5

CS/SPD Case Medical, Inc.…………………………………………… 43 MD Technologies inc.……………………………………… 42 Microsystems…………………………………………………… 36

DISINFECTION

HOSPITAL BEDS/PARTS INFECTION CONTROL Alco Sales Service, Co.…………………………………… 57 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…………… 4 Ruhof Corporation……………………………………………2, 3 TBJ Incorporated………………………………………………… 5 TIDI……………………………………………………………………17, 19 TRU-D………………………………………………………………… 22

INSTRUMENT STORAGE/TRANSPORT Case Medical, Inc.…………………………………………… 43 Cygnus Medical…………………………………………………… 9 TIDI……………………………………………………………………17, 19

INSTRUMENT TRACKING Case Medical, Inc.…………………………………………… 43 Microsystems…………………………………………………… 36

MONITORS Doctors Depot………………………………………………… 48 Pacific Medical………………………………………………… 55

ONLINE RESOURCE MedWrench……………………………………………………… 42

Case Medical, Inc.…………………………………………… 43 Cygnus Medical…………………………………………………… 9 Ruhof Corporation……………………………………………2, 3

OR TABLES/BOOMS/ACCESSORIES

DISPOSABLES Alco Sales Service, Co.…………………………………… 57

AIV Inc.…………………………………………………………………15 TRU-D………………………………………………………………… 22

ENDOSCOPY

PATIENT DATA MANAGEMENT

Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…………… 4 MD Technologies inc.……………………………………… 42 Mobile Instrument Service & Repair……………… 6 PRN/ Physician's Resource Network…………… 53 Ruhof Corporation……………………………………………2, 3

MAC Medical, Inc……………………………………………… 49

FALL PREVENTION Alco Sales Service, Co.…………………………………… 57

62 | OR TODAY | NOVEMBER 2018

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

SAFETY Healthmark Industries Company, Inc.…………… 4 TIDI……………………………………………………………………17, 19

SINKS TBJ Incorporated………………………………………………… 5

STERILIZATION 3M……………………………………………………………………… 27 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…………… 4 TBJ Incorporated………………………………………………… 5

SURGICAL MD Technologies inc.……………………………………… 42 TIDI……………………………………………………………………17, 19

SURGICAL INSTRUMENT/ACCESSORIES C Change Surgical………………………………………………13 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…………… 4

Innovative Medical Products…………… 38-41, BC

TELEMETRY

OTHER

AIV Inc.…………………………………………………………………15 Pacific Medical………………………………………………… 55

PATIENT MONITORING AIV Inc.…………………………………………………………………15 Jet Medical Electronics Inc…………………………… 53 Pacific Medical………………………………………………… 55 PRN/ Physician's Resource Network…………… 53

POSITIONING PRODUCTS Cygnus Medical…………………………………………………… 9 Innovative Medical Products…………… 38-41, BC

TEMPERATURE MANAGEMENT C Change Surgical………………………………………………13 MAC Medical, Inc……………………………………………… 49

TEST EQUIPMENT PRN/ Physician's Resource Network…………… 53

WARMERS MAC Medical, Inc……………………………………………… 49

WASTE MANAGEMENT MD Technologies inc.……………………………………… 42 TBJ Incorporated………………………………………………… 5 Medline………………………………………………………… 20-21

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