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OR TODAY | February 2019

contents features

KEEPING UP WITH THE ASCQR PROGRAM Each year, when CMS issues updates to its final payment rule for ASCs and hospital outpatient departments (HOPDs) for the coming year,

KEEPING UP WITH THE

ASCQR PROGRAM 25

THE VALUE OF SELF-AWARENESS

MARKET ANALYSIS

According to a recent report, the global medical carts market is expected to Self-awareness is the cornerstone generate revenue of about $4 billion by the of emotional intelligence. When end of 2024, growing at a compound annual you understand the strengths and weaknesses of your behavioral, cognitive growth rate (CAGR) of around 13.7 percent between 2018 and 2024. and motivational styles, then you can become a better self-manager.

it includes updates to the data collection, data submission and program administration requirements ASCs need to be in compliance with Medicareâ&#x20AC;&#x2122;s ASCQR reporting program. We look at the CMS 2019 payment rule for ASCs and HOPDs.

CE ARTICLE

When patients are severely immunosuppressed, they are at increased risk of developing serious fungal infections; nurses and other health care professionals play a key role in helping them understand the need to adhere to infection-control protocols that will reduce their exposures to pathogens in the environment. This module fills any gap in knowledge about the prevention strategies of these life-threatening fungal infections.

OR Today (Vol. 19, Issue #2) February 2019 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 30269-1530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530. For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. ÂŠ 2019

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INDUSTRY INSIGHTS 10 News & Notes 16 IAHCSMM 18 ASCA 20 CCI Commentary 22 Webinar Recap 25 Bobinski

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IN THE OR

27 Market Analysis 28 Product Focus: Medical Carts 32 CE Article: Life-Threatening Fungal Infections on the Rise

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news & notes

AAAHC Report Outlines High Compliance Areas, Opportunities for Improvement A report from AAAHC analyzed data from more than 900 accreditation surveys from 2017 to identify areas of high and low compliance, providing ambulatory health care organizations with insight on how best to improve performance and quality of care. Designing and implementing quality improvement studies, credentialing and privileging, as well as documentation management were common deficiencies cited during 2017 accreditation surveys. “The goal of this report is to increase understanding of AAAHC Standards and provide useful benchmarks to help organizations improve the quality of care provided to patients,” said Noel Adachi, president and CEO of AAAHC. “While the report indicates most facilities surveyed are in compliance with the majority of standards, there are a few focus areas where deficiencies persist.” The AAAHC Quality Roadmap 2018 gathered and analyzed data from on-site accreditation surveys rated against the 2017 AAAHC Standards. Organizations surveyed include ambulatory surgery centers (ASCs), Medicare Deemed Status (MDS) ASCs, office-based surgery facilities and primary care settings such as student, community, and occupational health clinics. AAAHC Quality Roadmap 2018 results indicate that the top overall deficiencies cited in more than 11 percent of survey ratings were consistent with 2017 results. Despite these high deficiency findings, the Quality Roadmap did note that organizations have demonstrated improvement from last year’s findings for conducting quality improvement studies, as well as documenting allergies and untoward drug reactions in patient clinical records. AAAHC’s analysis indicates that accredited organizations demonstrated high compliance with several standards and have shown improvement in key areas, including:

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Non-Medicare Deemed Status Standards · Timely consultation and referral for patients · Verification that patients understand how to use newly issued medical devices · Agreements with another provider group or nearby hospital for patient transfer in the case of an emergency Medicare Deemed Status Standards · Timely patient transfer information · Investigation of all patient grievances · Use of performance measures to improve outcomes A key component of accreditation is continuous quality improvement which demonstrates an organization is regularly monitoring performance and making adjustments when needed. A well-organized quality improvement program requires conducting ongoing studies that include documentation of corrective action and re-measurement to determine correction effectiveness. Without re-measurement, the quality improvement study is incomplete because there is no way of knowing whether improvement has actually occurred. “Our Quality Roadmap is designed to help ambulatory providers understand the most common deficiencies relevant to their setting and compare the findings to their own survey ratings and self-assessments to gauge performance,” said Naomi Kuznets, Ph.D., AAAHC Institute vice president and senior director. “We encourage organizations to leverage the report, as well as other AAAHC educational resources and toolkits and review policies, procedures, and practices to improve quality of patient care.” • The AAAHC Quality Roadmap 2018 is available for download at www.aaahc.org. •

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INDUSTRY INSIGHTS

news & notes

2018 AARC Zenith Award Honors Dräger The American Association for Respiratory Care (AARC) honored Dräger as a recipient of the 2018 Zenith Award during its 64th International Respiratory Conference in Las Vegas. This “people’s choice award” of the respiratory profession honors companies for their quality solutions, customer service and support. AARC members, which include 47,000 respiratory professionals across the U.S., were asked to vote on 300 manufacturers, service organizations and supply companies based on their quality of equipment, supplies or services; accessibility and helpfulness of sales personnel; responsiveness; service record; truth in advertising; and support of the respiratory care profession. Based on the voting, Dräger was selected as one of just six companies to receive the 2018 Zenith Award. “We are extremely proud of our long-standing relationship with the AARC and exceptionally grateful that its members have honored our company with this award for the ninth time,” said Edwin Coombs, MA, RRT-NPS, ACCS, FAARC, director of marketing, Intensive Care, Dräger. “The fact that the Zenith Award is a people’s choice award for the respiratory community, voted on by those individuals who are using our solutions everyday, makes it all the more meaningful. It speaks to the dedication of our people, the quality of our solutions and the commitment of our company to exceptional patient care.”•

SteriBump Frees Up OR Sterile Assistants Innovative Medical Products’ (IMP) pre-sterile Universal SteriBump is a multi-use, foam support that is ideal for shoulder abduction during lateral shoulder arthroscopy, incision closure of total hip or knee surgery, vascular surgery, extremity trauma and carpal tunnel procedures. SteriBump’s contoured, cradle-shape design provides a more secure elevated positioning of the patient’s extremities in the sterile field, and its overall rectangular shape offers a choice of multiple heights and angles. Latex and lint free, IMP’s rigid polyurethane-foam platform will not shift or move during surgery as often happens with cloth bundling. Using the SteriBump is easier, faster and safer than bundling cloth towels for surgical procedures. With the single-use SteriBump, there is never a question of sterility – eliminating cross contamination. The IMP solution not only reduces the potential for foreign particulates becoming airborne and entering a surgical site, but the sterile platform’s consistent size and stable density prove to be less costly and less labor-intensive than having OR staff put to-

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gether a handmade cloth bundle. SteriBump’s guaranteed sterility also frees up operating room scrub techs, nurses, or physician assistants from having to hold a limb during certain surgical procedures or having to bundle together sterile towels and other cloths to create a makeshift limb support. With the Universal SteriBump, it’s like having an extra pair of hands in the OR. •

FEBRUARY 2019 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

Diversey Launches One-Step, DfE-certified Disinfectant Diversey recently introduced SureTouch, a ready-to-use, onestep cleaner disinfectant and deodorizer that is powered by Accelerated Hydrogen Peroxide (AHP) technology. The product has been certified under the Environmental Protection Agency’s Design for the Environment (DfE) labeling program, which recognizes least-hazardous classes (i.e., III and IV) of EPA’s acute toxicity category hierarchy. “Our SureTouch disinfectant is environmentally responsible and delivers exceptional performance, making it the ideal product for facilities looking to clean and disinfect high-touch surfaces efficiently and effectively,” said Justin Carrier, Vice President, Contractors, Government, Education & Light Industrial-North America, Diversey. “The ready-to-use format ensures

that employees no longer have to mix and measure chemicals, allowing them to create safer and more satisfying environments of care, learning or work.” Highly compatible with a wide variety of hard, non-porous surfaces, the SureTouch disinfectant is effective against key bacteria and viruses including MRSA, VRE, Influenza and Norovirus. The product disinfects in just five minutes and can be used as a 30-second sanitizer on non-food contact surfaces. Additionally, SureTouch disinfectant’s active ingredients break down to oxygen and water after use, and it is non-irritating to eyes and skin. • For more information, visit www.diversey.com.

DNV GL Healthcare Launches U.S. Sterile Processing Program Certification DNV GL Healthcare has introduced a certification program for health care facility sterile processing departments. DNV GL’s Sterile Processing Program Certification provides validation that hospitals and other health care facilities meet or exceed standards of care. The Sterile Processing Program Certification is designed to recognize excellence in an organization’s sterile processing department within the scope of infection prevention and control, surgical services, endoscopic services and related departments. DNV GL is the first in the United States to offer a sterile processing program certification for an institution. One of the most important parts of DNV GL’s certification process is the requirement that the certified provider’s sterile processing department engage in continuous process improvement. As part of the certification, quality improvement initiatives, performance measures and/or clinical indicators are

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presented and discussed by staff at least quarterly. Instruments and equipment must also be tested at least quarterly to validate all sterilization processes. As part of DNV GL’s certification process, providers are required to track surgical site infections 90 days following surgery, not just during the hospitalization period. “A sterile processing certification is particularly crucial at a time when the complexity of medical instrumentation presents a challenge to maintaining sterility of the instruments used,” said Patrick Horine, president of DNV GL Healthcare. “DNV GL’s sterile processing program certification provides a path to enhancing such efforts.” Hundreds of hospitals across the United States have switched to DNV GL Healthcare over the past decade. The organization accredits more than 500 hospitals in 49 states. •

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Geisinger Launches Program to Reduce Opioid Use Geisinger has announced the launch of ProvenRecovery, a surgical redesign program aimed at expediting healing, improving pain management and reducing opioid use. The program will be implemented across 42 surgical procedures impacting approximately 15,000 surgery cases annually, with the goal of reaching 100 surgical specialties by the end of 2019. ProvenRecovery combines the best practices of Geisinger’s ProvenCare program in cardiac, bariatric, spine and joint surgical care, along with industry best practices in optimizing patients for elective surgeries. The ProvenRecovery pilot, which began in June 2017, has driven an 18 percent decrease in opioid usage across the organization. During the pilot, neurosurgery and colorectal surgery patients saw their hospital stays cut in half. Earlier discharges accounted for an average savings of $4,556 per case for colorectal surgery patients. “In my 35 years in surgery, this is the innovation with the greatest potential to improve the patient experience, save lives, reduce complications and be less disruptive to patients,” said Neil Martin, MD, Geisinger’s chief quality officer and chair of Geisinger’s neuroscience institute. “With ProvenRecovery, we are empowering patients to be healthier before surgery, leading to fewer surgical complications and patients returning to their lives sooner.” ProvenRecovery focuses on three key measures to empower patients to be healthier before and after surgery: proper nutrition, appropriate pain management, and mobility postsurgery. ProvenRecovery is the latest innovation from Geisinger, building on the organization’s work in genomic medicine with the MyCode Community Health Initiative research, and addressing food insecurity and diabetes through its Fresh Food Farmacy. •

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INDUSTRY INSIGHTS

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Hologic Launches Three-in-One Omni Hysteroscope Hologic Inc. has announced the U.S. launch of its Omni hysteroscope, an innovative three-in-one modular scope with advanced visualization capabilities designed for both diagnostic and therapeutic hysteroscopic procedures. Physicians can use the new Omni hysteroscope in their offices, surgical centers or operating rooms. “Experts agree that direct visualization of the uterine cavity in women with abnormal uterine bleeding is the gold standard that allows physicians to accurately identify and collect quality samples and remove pathology – in a safer and more effective manner than blind biopsy and curettage,” said Edward Evantash, M.D., medical director and vice president of global medical affairs, Hologic. “Featuring three easily interchangeable sheaths in one scope, our new Omni scope gives physicians excellent visualization capabilities with the convenience of seeing and treating pathology in a more streamlined procedure.” The Omni scope, which received 510(k) clearance by the U.S. Food and Drug Administration (FDA), is designed to help physicians streamline the process of diagnosing and treating patients. Oftentimes, a physician requires a diagnostic scope to look in the uterine cavity for fibroids or polyps, and then

14 | OR TODAY | FEBRUARY 2019

switches to an operative scope to biopsy or treat the pathology. With the new Omni scope, physicians can use the same scope with different sheath options to conveniently see and treat pathology. Additional features include: • Premium MyoSure optics for quality visualization and clarity throughout the procedure. • Sheaths designed with smaller diameters (3.7 mm diagnostic sheath; 5 mm operative sheath; 6 mm operative sheath) to reduce dilation required and promote patient comfort and easy insertion. • Long 200 mm working length facilitates easier access and treatment for obese patients. • Simple assembly and disassembly so sheaths can be changed out easily between procedures. • Operative sheaths can be used with Hologic’s Fluent hysteroscopic fluid management system. • Compatible with all MyoSure tissue removal offerings including MyoSure REACH, MyoSure XL, MyoSure LITE, and MyoSure MANUAL devices. •

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Philips Debuts Noninvasive Ventilator With High Flow Therapy

INDUSTRY INSIGHTS

news & notes

Royal Philips has announced the Philips V60 Plus ventilator has received CE mark approval. This comprehensive solution expands on Philips’ noninvasive ventilation (NIV) gold standard platform, integrating both NIV and high flow therapy (HFT) in a single device. Clinicians can rapidly adjust therapies around constantly changing patient conditions without having to switch devices. Designed for early intervention in respiratory failure, the V60 Plus enables clinicians to further enhance patient outcomes with less invasive respiratory care therapies, while improving clinician workflow and maximizing equipment investments. Patients with acute respiratory failure require immediate attention from caregivers. While early implementation with NIV is associated with less endotracheal intubation, as well as the reduction of serious complications and adverse events in the ICU, clinicians sometimes face challenges when weaning patients off of this therapy. The V60 Plus now delivers a wide range of non-invasive support for these patients, which supports clinicians to begin the weaning process sooner. By having the different, but complementary modes in one device, the V60 Plus can simplify workflow and device availability. “When treating respiratory patients in intensive and emergency care settings, it’s critical for clinicians to be able to wean efficiently or to quickly escalate care depending on their patient’s condition and specific needs. This often means complex workflows and alternating devices in time-sensitive situations,” said Jim Alwan, business leader of Philips Hospital Respiratory Care. “We are excited to offer a comprehensive noninvasive solution that enables quick therapy and interface transitions, so clinicians can focus on providing for their patients while spending less time setting up equipment.” The V60 Plus has received CE mark and is available for sale in Europe, and the U.S. Food and Drug Administration (FDA) 510k has been submitted. •

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IAHCSMM

IAHCSMM Webinars: A Convenient Way to Learn and Earn CE Credits By Julie E. Williamson ontinuing education and a commitment to knowledge advancement is essential for the long-term success of any Central Service/Sterile Processing (CS/ SP) professional. Whether an individual is new to the profession or is a seasoned veteran (or falls somewhere in-between) and is seeking educational resources to elevate their knowledge, stay current on industry standards and best practices, brush up on the basics or sharpen their technical or managerial acumen, IAHCSMM has them covered. And now, IAHCSMM is offering webinars to the evergrowing array of educational resources available.

“Webinars provide a terrific learning opportunity – and the fact that they are accessible from a desktop computer, laptop, tablet or even a smartphone makes them even more beneficial for today’s busy professionals,” said IAHCSMM Education Director Natalie Lind, CRCST, CHL, FCS. “Continuing education (CE) credits can be easily earned whenever and wherever is best for the individual.” As of press time, nearly 400 webinars have been viewed, which supports the notion that CS/SP professionals are interested in educational offerings that offer greater flexibility and accessibility.

Convenient, efficient, affordable Webinars offer users unsurpassed convenience, affordability and efficiency. The webinars are available over the Internet and can be accessed directly on any web-enabled device; this means they can be quickly and easily accessed anywhere and at any time. Because of this benefit,

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many professionals are using webinars as a time-efficient, cost-effective way to train staff and enhance their knowledge and skill sets. Additionally, there are no travel costs associated with participating in a webinar (and IAHCSMM members can participate in the webinars for free). Although webinar participation is a convenient, affordable way for individuals to advance their knowledge and gain CE credits, the webinars can also be beneficial for general staff/group training (e.g., for staff orientation and inservices). Most webinars are also relatively brief in length (great for time-crunched CS/SP professionals); however, they still feature valuable educational content. This lets participants gain knowledge that can help them improve quality, safety and performance on the job – but without a significant time commitment. “An online webinar library also allows participants to review the presentations multiple times to help them revisit the materials for reference and apply the contents on an as-needed basis,” reminded Lind.

A growing repository The series of webinars is offered at no cost to IAHCSMM members (non-members pay $15 per webinar). The webinars cover a variety of topics that can be used for general CS/SP learning and fall under the following categories: Employee Enrichment, Employee Training and Management. Current webinar topics include: • Behind Closed Doors: The Role of Central Service in Infection Prevention • Central Service Attire • Developing Teaching and Training Skills • Gamification

• • • • • • • • • • • • •

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“Additional webinars are currently under development and the webinar library will continue to grow across all categories to help employees and managers advance their knowledge and help them brush up on some of the essential basics,” said Lind. Following each webinar, users will take a brief survey to receive 1 CE credit that can be applied toward certification renewals. Visit www.iahcsmm.org/webinars for more information and to gain access to the full webinar library. Please note: Once a webinar has been purchased, the user will have access to view the content through their IAHCSMM account portal. If one’s membership is in good standing, the cost of each webinar will show as $0 in the shopping cart; simply complete the $0 payment to gain access to the webinars. – Julie Williamson serves as IAHCSMM’s communications director and editor. She has written hundreds of articles on topics related to central service, surgical services, infection prevention and materials management. WWW.ORTODAY.COM

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INDUSTRY INSIGHTS ASCA

Years of Advocacy Lead to Improved Access to ASCs By William Prentice hanks to decades of advocacy driven by ASCA and ASC supporters across the country, ASCs are starting 2019 with some new policies and programs in place that we expect to help patients gain increased access to the topquality, high-value outpatient surgery care that ASCs provide.

Several of the new policies came with release of Medicare’s final ASC payment rule back in November. In this rule, after years of requests from the ASC community, the Centers for Medicare & Medicaid Services decided to begin using the hospital market basket rather than the Consumer Price Index for All Urban Consumers (CPI-U) to determine the amount of the annual inflation update ASCs receive under the program each year. ASC advocates have long maintained that the hospital market basket, a reflection of the cost of a mix of goods and services involved in providing hospital services, was a far more appropriate measure of inflation in ASCs than the CPI-U, which is based on the cost of consumer goods like gasoline and bread. CMS’ decision to use the hospital market basket for ASCs also means that ASC inflation updates are now being determined using the same update factor as hospital outpatient

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departments (HOPD). This should help curtail the growing disparity between ASC and HOPD reimbursement rates that we have seen since the ASC payment system was tied to the HOPD payment system back in 2008. Although payments for the two sites of service will not be equalized under this new rule, the ASC community was not asking for parity and applauds CMS for this decision. Another important change introduced in the 2019 payment rule is the reduction of the threshold definition of device intensive procedures in ASCs from 40 percent to 30 percent of the overall cost of the procedure in the HOPD setting. Thanks to this lower percentage, we estimate that ASCs can now provide 124 procedures to Medicare beneficiaries that they could not provide before due to the expense of the devices involved. Because Medicare’s 2019 payment rule also expands the definition of surgery to include “surgerylike” procedures, ASCs are now able to provide an additional 12 cardiac catheterization procedures, plus five other procedures typically performed alongside those codes, to Medicare beneficiaries. ASCs have been performing these procedures with excellent outcomes for patients outside the Medicare program for some time and welcome this expanded access for Medicare patients.

The payment rule also contains other policies that support patient access to ASCs, including affirmation that new procedures added to the ASC list of payable procedures in the last few years have been added appropriately and separate payment for non-opioid pain control. Thanks to the support that ASCs enjoyed on Capitol Hill in the last two years, two important pieces of legislation were adopted that we expect to have far-reaching effects on patient access to ASCs in 2019 and beyond. The first, the VA MISSION Act, reforms the U.S. Department of Veterans Affairs (VA) health care system, creates a Veterans Community Care Program and institutes a new, more reliable claims reimbursement process within VA that should allow ASCs to serve more veterans. The second, the 21st Century Cures Act signed in December 2016, mandated that CMS develop a tool allowing the public to compare average costs between HOPDs and ASCs for outpatient surgery procedures performed in both settings. That tool – Procedure Price Lookup – came online in December. Of course, there is no substitute for the conversations patients need to have with their physicians before having surgery, but this tool goes a long way in empowering patients to make informed decisions about WWW.ORTODAY.COM

their care and containing the cost of that care. ASCA extends its thanks to all the members of the ASC community who have devoted long hours of dedicated service to educating their elected and appointed officials about the many benefits ASCs provide. The ASC community thanks all the policymakers who have listened, recognized the many benefits ASCs offer and acted to support the ASC model of care. As I write this message, other proposals CMS issued last year to reduce the regulatory burdens ASCs face are still pending. ASCA is also continuing to work with the agency to fine tune our quality reporting program and look at expanded opportunities for collaboration. On Capitol Hill, we are looking forward to continuing to work with our many champions who have emerged there over many years and beginning to get to know those who are serving for the first time. We expect 2019 to be another important year for ASCs and invite everyone working in or with an ASC to join us in our advocacy efforts. If you would like to be more involved, please contact Danielle Kaster at dkaster@ascassociation.org. If you want information about membership, please contact Mykal Cox at mcox@ascassociation.org.

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INDUSTRY INSIGHTS CCI

Mission Possible By Dawn Whiteside

ost facilities have their mission, vision and values statements in a poster within the hospital in various locations. I often wonder how many team members really look at these statements. A mission statement explains the organization’s core purpose in broad terms and the reason for existence.1 Establishing your organization’s reason for being and core values is essential to developing the overall vision for your organization.

You may wonder, “Why is this important to me?” The most important asset of any organization is the people. Without team members and clients/patients, an organization would not succeed. Understanding the value of people is just one aspect of a successful mission. Understanding and, more importantly, believing in the mission of your organization should give you a sense of pride and ownership. Professionals bring a wealth of knowledge, skills and experience to the organization. Recognizing those diverse characteristics only strengthens the organization. Professional accountability means a person is responsible for his or her own actions. “In today’s complex and dynamic world, we must go beyond mere accountability and foster a culture of ownership where people hold themselves accountable because they have personal buy-in to the values and mission of their hospitals.”2 When you walk into your place of work, do you feel happy and enthusiastic to be there? Those who feel a sense of ownership, find value and happiness in

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what they do every day and it shows. How great would it be to be surrounded by teammates who have a passion for what they do? Having passion is loving your work and it shows to those around you. Passion leads to an individual being fully engaged and present both physically and emotionally. Creating a positive culture of ownership takes time and commitment. Building a positive culture of ownership must involve zero tolerance for behaviors that are in stark contrast to your mission, vision and values as an organization. If you think of your organization as a structure of building blocks, the foundation would be your values. Values are what all behaviors are built upon. Clear expectations of what the important values are to your organization should be understood by the entire team. If the expectation is that all team members will demonstrate the foundational values, but behaviors in direct conflict with those values are tolerated that is what becomes the new expectation. The culture of your organization is the second building block that lives on top of the foundation of values. A positive culture of ownership involves accountability. Team members are accountable for the work they do but not just what is listed in the job description. There is a behavioral component that many times is left out or just ignored. Every team member’s attitude affects peers and clients/patients. Expecting a culture that is positive, professional and promotes pride in his or her profession, organization, work and self is a great first step toward developing a culture of ownership. This culture will

accept the mission, vision and values of your organization. The Competency and Credentialing Institute (CCI) has just revised its mission and vision statements to demonstrate our commitment to promoting safe patient care and our collaborative relationship with our nursing partners. Our new statements are as follows:

Vision Statement A growing community of lifelong learners for whom CCI is a catalyst and integral partner.

Mission Statement To lead competency credentialing that promotes safe, quality patient care and professional development through lifelong learning. Having team members that accept the mission, vision and values of the organization is not impossible. Mission possible is creating an environment that builds on the foundation of organizational values.

References: 1. Daft RL. The Leader as Social Architect. In: The Leadership Experience. 7th ed. Clifton Park, NY: Cengage Learning; 2018:407-410. 2. Tye J. and Schwab D. The Florence Prescription From Accountability to a Culture of Ownership The Next Frontier for Patient Satisfaction, Workplace Productivity, and Employee Loyalty. Solon, IA: Values Coach, Inc; 2009.

– Dawn Whiteside MSN-Ed, RN-BC, CNOR, RNFA, is the director of education at the Competency & Credentialing Institute. WWW.ORTODAY.COM

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INDUSTRY INSIGHTS

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Webinar: Professional Development is Changing Staff report he CCI-sponsored webinar “Professional Development in Healthcare is Changing. What Choice Will You Make?” received positive reviews from attendees.

The 60-minute webinar featured Jim Stobinski, CEO of the Competency and Credentialing Institute (CCI). American health care is changing rapidly through the ongoing transition to a value based system of care. Processes for ongoing professional development for American health care workers are also in the midst of large-scale change. In his presentation, Stobinski discussed factors causing changes in professional development practices. He also discussed the relevant organizations engaged in these changes. The evolving role of the registered nurse as the supervisor of unlicensed staff in the perioperative setting was also discussed. “The OR Today webinar series is very informative and accessible in bite-sized chunks, convenient and provides CEs ... thank you so

22 | OR TODAY | FEBRUARY 2019

much,” said M. Tuazon, clinical nurse educator. “This presentation wonderfully outlined the changes coming in professional development for credentialing ... I understand it so much better,” said J. Pirie, RN, learning resource manager. “This webinar on the changes to come for certification was extremely informative. The future is indeed scary, but any new process is scary until we get used to them,” said M. Diaz, nurse educator OR. “The webinar gave me great insight into the changes that are coming in nursing professional development and I think affirmed the need to be certified for both the benefit of the patients and myself,” said A. Lampani. “Adjusting to the ever-changing health care environment is vital. As nurses, we must ensure we are serving our patients to the best of our ability through education and continuous learning opportunities,” said R. Hicks, RN. “Jim’s presentation was realistic and gave me an idea of how I will have to plan for the professional develop of the nurses

working in the ASC our company manages. I appreciated the frankness of the presentation. I believe I can help our team prepare to accept the new requirements of professional development and instill a sense of pride to become professionally competent,” said B. Kirchner, CNO. “OR Today’s webinars are great. The topics are interesting. They usually stay on topic, are timely, and allow for interaction with viewers. They are usually timed for the lunch hour and they always provide numbers for contact people if you have a question later. Very user friendly,” said K. Stengel, quality and safety nurse specialist. “I like the timeliness of the topics the OR Today webinar series provides,” said T. Stanford, division nursing analyst. For more information about webinars, visit ORToday.com. Webinar sponsored by:

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INDUSTRY INSIGHTS

Self-awareness

The Value of Self-awareness By Daniel Bobinski or several millennia, people have realized the value of self-awareness. In fact, the Greek phrase, “gnothi sauton,” (know thyself) was a common saying as far back as at least 550 BC. For the last 40 years or so, the phrase, “know thyself” has been the foundation for all reputable leadership training. And, for the last 25 years, self-awareness has been the starting point for learning emotional intelligence.

Self-awareness can be defined many ways, and at the risk of sounding philosophical, it has many layers, too. In his best-selling book “Emotional Intelligence,” Daniel Goleman defines self-awareness as “knowing one’s internal states, preference, resources and intuitions.” My definition is a little simpler, but covers similar territory: “Perceive and assess our own emotions, desires and tendencies.” The way that I teach it, a good starting point for knowing yourself includes understanding your behavioral style, which includes your strengths and weaknesses. This is not always easy! I remember when my first coach had me take a DISC Assessment almost 30 years ago. Among other WWW.ORTODAY.COM

things, it pointed out my strengths and weaknesses. On the outside I tried to look composed, but inside I was devastated! Right there on the paper it was saying I had weaknesses! I didn’t want weaknesses. I wanted only strengths. As it turns out, simply knowing that you have strengths and weaknesses is just one level of self-awareness. It’s coming to grips with those weaknesses that takes you to a whole different level. By doing so, you develop not just self-awareness, you also gain self-acceptance by realizing that you are capable in some areas, and not as capable in others. I’m being transparent with my story because I want you to understand how it works. Part of the reason that self-awareness is the cornerstone of the EQ model is that you develop some grace and mercy toward yourself. Then, when you own that – when you come to grips with accepting your own weaknesses – then you have a foundation for being able to display empathy toward others. And empathy is vital when practicing emotional intelligence. I firmly believe that it’s hard to understand others in any real depth if you don’t have a gracious understanding and acceptance of your own

strengths and weaknesses. After behavioral style, another area we need to be aware of is our cognitive style – the strengths and weaknesses in how we notice and process information plus how we make decisions. It’s also valuable to understand our personal motivations. Some are innate and some are learned, but motivations drive our behavior, and it’s good to be consciously aware of what drives us. Remember, we can’t stop at just knowing these things about ourselves. The real value of self-awareness comes in accepting ourselves as we’ve been designed. Bottom line, self-awareness is the cornerstone of emotional intelligence. When you understand the strengths and weaknesses of your behavioral, cognitive and motivational styles, then you can become a better self-manager. But that’s a topic for a different column. – Daniel Bobinski, M.Ed., teaches teams and individuals how to use Emotional Intelligence, and his videos and blogs on that topic appear regularly at www.eqfactor.net. He’s also a best-selling author and a popular speaker at conferences and retreats. Reach him at daniel@ eqfactor.net or (208) 375-7606. FEBRUARY 2019 | OR TODAY |

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Global Medical Carts Market Will Reach $4 Billion by 2024 Staff report ccording to a Zion Market Research report, the global medical carts market was valued at approximately $ 1.65 billion in 2017 and is expected to generate revenue of around $4.05 billion by the end of 2024, growing at a compound annual growth rate (CAGR) of around 13.7 percent between 2018 and 2024.

Growing health care expenditure has raised the demand for a large number of equipment, one of which is medical carts that are required for error-free movement of medical supplies on specific premises. Rising number of hospital admissions and the growing number of surgical procedures have raised the demand for medical carts in recent years. Growing focus on ensuring patient safety and improving nursing efficiency has augmented the demand for medical carts. The availability of customized medical carts suitable for medical needs has improved the sales of these carts. Today, medical carts are customized for dispensing, transporting and storing medical instruments and drugs. Depending on the nature of procedures or cartsâ&#x20AC;&#x2122; usage, manufacturers are offering customized solutions in order to increase sales. The growing number of point-of-care diagnostics with better configuration, construction, options and features to meet the requirements of consumers is also likely to WWW.ORTODAY.COM

boost the market growth for medical carts. The medical carts market is divided on the basis of product into mobile computing carts, medical carts, wall mount workstations and medical cart accessories. The mobile computing carts segment is further sub-divided into telemedicine carts, computer carts, medication carts and documentation carts. The medical carts segment is further sub-divided into procedure carts, emergency carts, anesthesia carts and other carts. The wall mount workstations market is further bifurcated into wall cabinet workstations and wall arm workstations. The emergency medical carts dominated the market in 2017, as these carts are well-equipped with medical devices and are easy to clean. They are widely used during emergencies, such as cardiac arrest and other surgeries. Advancements related to lighter weight designs, enhanced ergonomics and improved mobility are other factors propelling the demand for adoption of these carts. The material segment is classified into metal, plastic and wood. The plastic and metal segments are likely to dominate the medical carts market in the forecast period, owing to the cost-effectiveness of plastics and the availability of raw materials to manufacture highly advanced medical carts. Based on end-user, the market is divided into hospitals, nursing homes and long-term care centers, physician offices or clinics, and others. Hospitals hold the largest market

share. With the availability of mobile and advanced medical workstations, the market for mobile computing carts is growing in hospitals, as these carts can be moved across various departments in hospitals. The growing focus of patients on engagement and promotion of EHR incentive programs in the hospitals encourages patient involvement are some other factors responsible for the growth of hospitals segment in the medical carts market. North America and Europe are anticipated to be the leading markets for medical carts. The U.S. held a major share in the market and accounted for more than 80 percent of revenue in the year 2017. Medical computer carts are widely adopted as they reduce medication errors and enhance patient safety, thus favoring market growth. These carts are designed economically apart from being cost-effective, which further propels the market growth. New product launches by leading manufactures and technology advancements in North America and Europe along with government funding are likely to play a vital role in fuelling market growth. Asia Pacific is estimated to showcase the highest growth potential in the medical carts market and is also expected to grow at the highest CAGR in comparison to other regions. The Middle East and African and Latin American regions are also likely to be potential markets for medical carts. FEBRUARY 2019 | OR TODAY |

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HEALTHMARK HushKarts

The HushKarts are designed for quiet mobility with rubber-cushioned 4-inch sealed bearing casters. Designed for convenient storage, each HushKart offers three shelves with slip resistant surfaces and raised edges. Ideal for use as surgical case carts, and for use by pharmacy, respiratory and CSD. Designed for easy cleaning, its cart-washer washable. The one-piece, double-wall polyethylene construction (no creaking bolts and no rattling metal) will not rust, corrode, dent or peel. One-piece seamless construction eliminates hard-to-clean grooves and crevices. Available in three colors, establish a color-coding system to fit your needs. Choose a color (slate blue, dark brown, coffee beige) to coordinate with the dĂŠcor. â&#x20AC;˘

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Stainless Steel Casework MAC Medical’s full line of stainless steel casework can be configured in a number of ways to create the arrangement your facility needs. Choose from wall cabinets, base cabinets, high cabinets and operating room cabinets. New standard features include magnetic door catches with a quiet close and a seamless front face on all cabinets. Many optional features are available including cam locks, tee handles, electronic keypad door lock and sloping tops to name a few. Also, Revit® files and spec sheets are available for download. • To learn more, visit the casework section at www.macmedical.com.

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Life-Threatening Fungal Infections on the Rise By Luci Perri, MSN, MPH, RN, CIC, FAPIC

first encountered Aspergillus infection when I was a new nurse on a bone marrow transplant unit. I remember that my patient, a woman in her late 40s with leukemia, had received a bone marrow transplant and was severely neutropenic. Her Aspergillus infection started in her sinuses and spread within days into her facial structures, eyes, and then her brain. Although she received amphotericin B and extensive surgical debridement that left her with severe facial deformities, she died of cerebral aspergillosis within a few weeks of diagnosis.

The overall incidence of life-threatening invasive fungal infections has increased during the past several decades, partially due to an increasing population of immunosuppressed and critically ill patients.1-3 Those at high risk of acquiring fungal infections include patients with cancer with chemotherapy-induced neutropenia (an abnormally low number of neutrophils); transplant recipients receiving immunosuppressive therapy, such as corticosteroids or cyclosporine; patients with HIV; and patients in ICUs. The risk of infection has increased for critically ill patients with normal immune systems, as well. Aggressive treatments, diagnostic procedures, and complicated surgeries — along with the nearly universal use of broadspectrum antibiotics; long-term indwelling catheters (intravascular, peritoneal, or urinary); and total parenteral nutrition — have made these patients more vulnerable to hospital-acquired fungal infections.1-3 In addition to following basic infection WWW.ORTODAY.COM

control practices, all healthcare professionals need to educate these vulnerable patients, their families, and their caregivers about the importance of infection-control protocols to reduce their risk of developing invasive fungal infections while in the hospital and after discharge. Such patient education can save lives. The two most important species of fungi that cause invasive disease in hospitalized patients are Candida and Aspergillus. Both are associated with high morbidity, high mortality, increased length of stay, and a significant use of medical resources. Candida species are the major cause of invasive fungal infections in both critically ill immunocompetent (normal immune system) and immunosuppressed patients. In U.S. hospitals, Candida species account for 6% of all hospital-acquired infections, 70% to 90% of fungal infections, and 22% of bloodstream infections, making Candida the most frequently isolated healthcareassociated organism in bloodstream infections.2,4,5.6 Candida bloodstream infections have the highest mortality rate of all bloodstream infections, and for invasive disease (disseminated candidiasis), the mortality rate is similar to that of septic shock, 40% to 60%.1,2,6 In addition to the high mortality rates, invasive infections with Candida are responsible for an extra $2 billion in healthcare costs in the U.S. each year.5 Aspergillosis is the second-most common fungal infection, primarily involving the lungs in patients who are severely immunocompromised. It’s the leading cause of death in patients with leukemia and in those who undergo bone marrow transplants. The mortality rate for neutropenic patients with invasive Aspergillus infection is 25% to 59%.7

Relias LLC 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 39 to learn how to earn CE credit for this module.

Goal and objectives The purpose of this fungal infection continuing education program is to inform healthcare professionals about the two most common fungicaused invasive diseases in critically ill and immunosuppressed patients. After studying the information presented here, you will be able to: • Describe the two major risk factors for invasive Candida infections • Discuss three ways to prevent spread of Candida auris • Explain three ways invasive Aspergillus infections can be prevented

FEBRUARY 2019 | OR TODAY |

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34 | OR TODAY | FEBRUARY 2019

Risk factors

immunosuppressive Risk Factors for Development medications, or an exposure to an ICU environof Invasive Infections1,2 ment, where 50% to Aspergillus spe66% of all Candidemia Candida species cies infections occur.9 In the ICU, the widespread use • Prolonged ICU stay of broad-spectrum anti• Prolonged hospitalbiotics, total parenteral ization nutrition, mechanical • Neutropenia • Hemodialysis ventilation, and indwell• Transplantation • Neutropenia ing medical devices is • Corticosteroid • Broad-spectrum use especially favorable for antibiotics • Burns • Central venous the growth of Candida. catheters • Chronic Patients with indwelling granulomatous • Parenteral nutrition medical devices are at disease • Urinary catheters risk.1,2 Candida species • COPD • Burns have a special affinity • Graft-versus• Neonates host disease for biomedical materials • Mechanical ventila• Unfiltered air tion >3 days (e.g., plastics), and the • Contaminated • IV drug abuse increase in Candida inwater • Mucocutaneous fections during the past • Construction damage several decades has pardust • Immunosuppression • Potted plants/ alleled the increased use including corticoflowers steroids, chemoof implanted/indwell• Food therapy ing medical devices in • Abdominal surgery; patients with impaired anastomotic leak or immune systems.9,10 repeat laparotomies Candida cells can colonize medical devices — such as IV and • Endogenous • Airborne central venous cath• Hospital-associated • Waterborne hand contact eters, urinary catheters, • Foodborne • Vascular access surgical drains, feeding tubes, nasogastric tubes, pacemakers, stents, and • Kidney • Liver and spleen • Lung shunts — by forming • Eye • Sinuses dense microcolonies of • Spinal column • Brain cells entrapped within • Heart • Skin a polysaccharide matrix • GI tract • Bone (biofilm) attached to the • Bone (late) devices. This “slimelike” material protects the species has recently emerged as a global Candida cells from the body’s immune threat.2,8 In June 2016, the Centers for defenses and from most of the comDisease Control and Prevention issued monly used antifungal agents.2 a health alert about Candida auris, a globally emerging pathogen (https:// A New Threat www.cdc.gov/fungal/diseases/candidiasis/ Although the majority of healthcarecandida-auris-alert.html). By November associated fungal infections are caused by 2016, the CDC reported the first seven C. albicans, C. glabratta, C. parapsilosis, C. infections in the U.S. Unfortunately, four tropicalis, and C. krusei, another Candida of the seven (57%) initial case patients Mode of acquisition

Candida are yeastlike fungi that can be found in low concentrations as normal inhabitants of the human skin, oropharynx, and of the mucosal membranes lining the GI, genitourinary, and respiratory tracts.1,8 The organisms rarely cause invasive disease in humans unless an interruption of the body’s natural barriers, such as skin and mucosal surfaces, occurs, allowing the fungal pathogens to enter the bloodstream. This can happen when medical procedures break down skin and mucosal surfaces; with bacterial and viral infections, such as herpes simplex or cytomegalovirus; chemotherapy; radiation therapy; or graft-versus-host disease damage the skin and mucosa. It can also occur when antibiotics suppress the body’s normal bacterial microflora, allowing Candida to overgrow in the GI tract.1,2,8 In immunocompromised patients, an overgrowth of Candida can lead to life-threatening infections ranging from candidemia (Candida species in the blood) to widespread dissemination (candidiasis, sepsis, and multisystem failure). At high concentrations, Candida cells can pass across the intact gut mucosa and enter the bloodstream. From there, they can travel to the kidneys, brain, lungs, liver, heart, spleen, and pancreas.1,2,8 Most Candida infections are thought to be endogenous (acquired through previous colonization of the mouth, GI tract, vagina, or skin). But exogenous infections are possible, acquired by cross infection from another patient or a healthcare worker and contaminated equipment, solutions, and surfaces. One study of surgical ICU and neonatal ICU healthcare workers found Candida on 33% of surgical ICU and 29% of neonatal ICU healthcare workers’ hands. Another study identified a healthcare worker whose artificial nails were colonized with Candida as the source for postoperative candidal osteomyelitis.2 The two major risk factors for developing invasive Candida infections are prolonged immunosuppression, usually as a result of chemotherapy or other

Predominant organ involvement

How Candida Gets a Foothold

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died.11 As of July 2017, 98 cases of infection have been identified in nine states: Connecticut, Florida, Illinois, Indiana, Maryland, Massachusetts, New Jersey, New York, and Oklahoma. Patients on the same unit as the infected patients were screened as well, which resulted in finding colonized patients. Currently, 110 cases of colonization have been discovered.12 The estimated mortality rate for C. auris infection is 30% to 60%.13 Candida auris is particularly concerning because antifungal resistance is common and some isolates are resistant to all three major classes of antifungals, which is unusual for Candida.11,12 Due to this resistance pattern, the CDC advises obtaining an infectious disease consult for suspected or known infections.14 Currently, a new class of anti-fungal drugs, echinocandins, are recommended for initial treatment.9 (Level ML),14 Since C. auris is frequently misidentified by conventional laboratory methods, the CDC recommends using sequencing or mass spectrometry to accurately identify the species.15,16 Misidentification delays appropriate treatment in an already critically ill patient. Although this organism was first identified in 2009, it has caused clusters in several countries since 2013. The first outbreak in Europe occurred in an adult ICU in a London Hospital where 50 cases were identified over 16 months (April 2015-July 2016). Additionally, environmental sampling yielded positive cultures of the floor around the bed, radiators, windowsills, equipment monitors, key pads, and one air sample. This clearly demonstrates the viability of C. auris in the environment.17 According to the CDC, this organism can survive on environmental surfaces for weeks.11,18 C. auris not only contaminates the environment but also remains on skin and in body sites (e.g. urine, respiratory tract) for several months.11,18 This means patients can contaminate the environment for months, even after the infection resolves, which adds to the risk of transmission within healthcare facilities. WWW.ORTODAY.COM

In summary, the factors contributing to the concern about C. auris include: 1) multidrug resistance, 2) misidentification in the lab using standard culture techniques, 3) survival on environmental surfaces, 4) persistent patient colonization, 5) easily spread in the healthcare environment.

Aspergillus All Around Us Invasive aspergillosis is an acute, rapidly progressive, often fatal infection that primarily involves the lungs and central nervous systems of severely immunosuppressed patients. The infection is caused by Aspergillus, a filamentous fungus named in 1729 by a botanist who thought the fungal fruiting bodies resembled an aspergillum, a brush or perforated ball used for sprinkling holy water during church services. Exposure to Aspergillus is common. The fungus is ubiquitous in soil, water, food, and decaying vegetation. In the hospital, Aspergillus spores (conidia) can be isolated from the air, ventilation systems, water, contaminated ceiling tiles, carpeting, food, plants, flowers, and contaminated dust during construction. The two major risk factors for invasive aspergillosis are neutropenia and corticosteroid therapy. Patients at highest risk include those who have had stem-cell transplants (5% to 13%); those who have received liver, lung, and heart transplants (5% to 25%); and those receiving intensive chemotherapy for leukemia (10% to 20%).19 COPD is also a risk factor for Aspergillus infection among ICU patients without underlying malignancy.2,19,20 Mortality among critically ill patients ranges from 46% to 80%.20 Infections with Aspergillus nearly always occur from inhaling its spores, which then are deposited in the lungs, nose, or paranasal sinuses. When inhaled spores reach the lungs, pulmonary macrophages and neutrophils are the first line of defense against invasive disease. In the normal host, pulmonary macrophages can kill and ingest the spores. If a few spores escape the macrophages and

germinate, neutrophils can use extracellular mechanisms to destroy the hyphal (branching, threadlike filaments) forms.21 However, in patients with severely compromised immune systems, the spores are able to germinate, forming hyphae that can invade the lung tissues and blood vessels. The rapidly growing hyphae plug the vessels, disrupting the flow of blood. Areas of necrosis distal to the vascular obstruction develop, and erosion into the blood vessel walls can lead to massive pulmonary hemorrhage and exsanguination. Corticosteroid therapy further increases susceptibility to invasive aspergillosis by impairing the ability of the macrophages and neutrophils to kill spores and hyphae.22 The lungs are the primary focus of invasive Aspergillus infections.2,19 The usual clinical presentation is nonspecific with symptoms of pleuritic chest pain, low-grade fever, cough, dyspnea, and pulmonary infiltrates. In extensive infection, multiple nodular pulmonary infiltrates surrounded by a zone of low attenuation, the “halo” sign, can be seen on chest radiographs. Over time, the nodules can create a cavity, forming a thin crescent of air near the edge (“air-crescent” sign). Both signs are characteristic of invasive pulmonary aspergillosis.20 Respiratory tract infections can disseminate to other sites, including the eyes, brain, liver, spleen, kidney, and bone. Cerebral aspergillosis is the most lethal manifestation of invasive disease with a mortality as high as 100% reported in the literature.22 The fungus is disseminated usually to the brain through the bloodstream, although it may also be a result of direct extension from the sinuses, where inhaled Aspergillus spores have settled in the nasal turbinates, germinated, and invaded the bone, orbit, and brain. Clinical symptoms of central nervous system infections include focal seizures, hemiparesis, cranial nerve palsies, and hemorrhagic infarcts caused by vascular invasion.22 Current treatment recommendations include voriconazole (Vfend), that has been somewhat sucFEBRUARY 2019 | OR TODAY |

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cessful in several case reports and studies.20,22,23

Elusive Clues Infections with Candida and Aspergillus are extremely difficult to diagnose and may require sending specimens to outside clinical laboratories.2 The clinical symptoms of Candida are nonspecific. Often the only indication of infection is a gradual worsening of a patient’s clinical condition associated with a persistent, unexplained fever or sepsis that does not respond to broad-spectrum antibiotics. Since positive blood cultures are obtained in only 50% to 70% of patients with disseminated infection, non-culture based lab tests provide more accurate information but aren’t widely used.2,6,8,9,20 The beta-D-glucan assay, which detects a fungal cell-wall antigen, is available as an adjunctive diagnostic tool.2,9 Early diagnosis of Aspergillus infection is equally difficult. Not only are the clinical signs nonspecific, but clinical presentation varies among different patient groups. Blood cultures are rarely positive, and even with focal pulmonary lesions, sputum cultures are positive less than 50% of the time.19 In addition, the “halo” sign and “air-crescent” sign seen on CT chest scans are relatively late findings and are not usually seen until the disease has advanced, and the patient has recovered from neutropenia.20 Although molecular testing methods are available, they aren’t widely used. Therefore, the current recommendation is to obtain enough tissue and fluid specimens for concurrent histopathologic/cytologic and culture testing.23 Current practice guidelines recommend using galactomannan antigen (fungal cell wall antigen) for specific body fluids in very specific patient populations. BetaD-glucan assay is recommended only for patients with hematologic malignancies and specific hematopoietic stem cell transplant (HCST) subpopulations.23

36 | OR TODAY | FEBRUARY 2019

Treatment Can’t Wait Because early detection of invasive Candida and Aspergillus infections is nearly impossible, empiric antifungal therapy is initiated typically for febrile neutropenic patients who fail to respond to four to seven days of appropriate broadspectrum antibiotic therapy.5,8 Empiric therapy generally consists of antifungal agents active against Candida and Aspergillus species, such as the echinocandins (caspofungin [Cancidas] and anidulafungin [Eraxis]), amphotericin B lipid formulations (Abelcet), and voriconazole (Vfend).2,23 Patients diagnosed with or suspected of having an invasive Candida infection should receive systemic antifungal therapy. In addition, all IV catheters should be removed, as biofilms on catheters form a nidus (central point) for ongoing infection. Currently, the drugs used most frequently to treat candidemia are the echinocandins, voriconazole, and amphotericin B. Since fluconazole (Diflucan) has been used so widely as prophylaxis, primarily in neutropenic patients, resistance has become an issue in some Candida species. Therefore, it isn’t recommended any longer as primary empiric therapy, but can be used once sensitivities have been obtained.2,9 Invasive aspergillosis is highly lethal in patients who are immunosuppressed, and often treatment is initiated upon suspicion of diagnosis without definitive proof. Voriconazole is the drug of choice for treatment of invasive aspergillosis because of better tolerance and improved survival when compared with amphotericin. Caspofungin has also been approved to treat invasive aspergillosis in patients who cannot tolerate or are resistant to other therapies. Amphotericin is sometimes used with treatment failures.23

Healthcare Professionals Lead Prevention Efforts Despite aggressive medical treatment, the mortality rate for immunosuppressed patients with invasive Candida or Aspergillus infections remains unacceptably

high. For this reason, preventive measures are of major importance. Nurses and other healthcare professionals need to have a clear understanding of how and where Candida and Aspergillus infections are acquired to help prevent disease. Invasive Candida infections are predominantly endogenous, resulting from a prior colonization of the patient’s skin and mucosa. Nevertheless, with careful attention to the patient’s oral, dental, skin, and perineal hygiene, nurses and other team members can help reduce or suppress Candida colonization. Among obese patients, areas where two skin surfaces touch (intertriginous skin) should be kept clean and dry. Patients experiencing dry mouth should be encouraged to drink water, or if unable to drink, chlorhexidine mouth wash or a moisturizing product should be used.24 Because Candidemia is common, following the central line insertion practices (hand hygiene, maximal barrier protection, alcoholic chlorhexidine [CHG] skin prep, and avoiding the femoral site in adults) will reduce the risk of infection. Additionally, adherence to recommended maintenance practices including daily assessing the need for the central line, daily (CHG) bathing of ICU patients, and scrubbing ports and access points with an antiseptic will contribute to preventing central line infections.2,25,26 Lastly, educate the patient to remind anyone touching the central line or other devices to wash his or her hands first.2 Since C. auris is considered easily transmitted or spread, additional steps should be taken to prevent transmission. For all inpatient settings (hospital, long-term acute care hospitals, and nursing homes):27 • Contact the state or local health department and the Centers for Disease Control (CDC) and Prevention for guidance for suspected cases • Require scrupulous attention to basic hand hygiene for staff, patients, and visitors • Place colonized or infected patients in a room without roommates. Can place patients colonized with the WWW.ORTODAY.COM

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• •

•

same organism in the same room if private rooms aren’t available. Use standard and contact precautions for colonized and infected patients Special considerations for nursing homes: • Patients who can clean their hands before leaving their rooms; can contain bodily fluids and secretions; and do not have any indwelling medical devices (e.g. urinary catheters, gastrostomy tubes) may leave their rooms. • Staff should wear gown and gloves for any duties that risk contamination of hands or clothing, such as changing bed linens, bathing or dressing the patient, and changing wound dressings. • For patients going to physical, occupational, or recreational therapy: • Schedule at the end of the day to allow staff enough time for appropriate cleaning • Dedicate staff to the patient with C. auris so that therapy staff does not work with other patients at the same time • Staff should wear gowns and gloves when touching the patient or contaminated equipment. • Environmental surfaces and equipment should be disinfected before use for another patient Periodically reassess patients by swabbing axilla and groin to determine when contact precautions can be discontinued (see https://www.cdc.gov/ fungal/diseases/candidiasis/c-aurisinfection-control.html#disinfection for information about discontinuing precautions and subsequent admissions under the heading “Duration of Infection Control Precautions”). Clean and disinfect the room daily while occupied and after discharge with an Environmental Protection

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Agency-registered healthcare disinfectant capable of killing Clostridium difficile spores (https://www.epa. gov/pesticide-registration/list-k-epasregistered-antimicrobial-productseffective-against-clostridium) • Screen close contacts for presence of colonization (see https://www.cdc. gov/fungal/diseases/candidiasis/cauris-infection-control.html for more information) • Let receiving healthcare facilities know that the patient has this infection or colonization In addition to acute care and longterm care infection control measures, the CDC website also contains relevant infection control information for outpatient and home health settings. In contrast to most Candida infections, infections with Aspergillus are exogenous. They are nearly always acquired through inhalation of airborne spores from the environment. Given the ubiquitous presence of Aspergillus in the environment and the uncertainty of the incubation period for infection, it is often difficult to determine whether aspergillosis was acquired inside or outside the hospital. However, because most patients undergoing chemotherapy or bone marrow and solid organ transplants spend their most vulnerable, neutropenic period in the hospital, many Aspergillus cases are assumed to be a result of exposure during hospitalization. Air contaminated with Aspergillus spores is the major source of hospitalassociated aspergillosis. Numerous outbreaks of disease have been associated with dust-laden air from hospitals or nearby construction sites. To lessen exposure to airborne Aspergillus spores, many neutropenic patients are placed in a protected environment during hospitalization. This environment includes rooms with the following:28,29 • High-efficiency particulate air (HEPA) filtration of incoming air • Positive air pressure relative to the corridor

• Well-sealed walls, floors, ceilings, windows, and electrical outlets to keep out unfiltered air • Ventilation to provide at least 12 air changes per hour • Strategies to lower dust (e.g., no carpeting or upholstered furniture) • Routine cleaning and disinfection using daily damp dusting • A ban on dried or fresh flowers and potted plants in patient rooms and other hospital areas of patient exposure When patients leave their protected environment for diagnostic studies or treatments, they should wear N95 respirators if dust generating, construction, or renovation is occurring in or near the hospital. The CDC does not currently recommend patients wear an N95 mask outside of these circumstances since this topic has not been adequately evaluated.29 Additional infection control measures include placing high-risk hospitalized patients away from any construction or renovation projects within the facility; use vacuums with a HEPA-filtered vacuum to decrease exposure to aerosolized Aspergillus.29 Hospital water and food have been implicated as sources of Aspergillus infections. Waterborne Aspergillus can aerosolize, especially in bathrooms, where sinks, showers, toilets, and drains are potential sources for transmission of spores. Aspergillus is also found in ice-making machines and refrigerator condensate trays. Although there are no specific guidelines for preventing exposure to Aspergillus in hospital water, it makes sense that healthcare professionals should help neutropenic patients minimize their exposure to activities that cause water aerosolization. For example, bed baths might be used instead of showering, and commercially bottled sterile water might be provided for drinking and brushing teeth instead of tap water. Nurses and other healthcare professionals might also caution highrisk patients to avoid exposure to faucet FEBRUARY 2019 | OR TODAY |

IN THE OR

continuing education

water, humidifiers, and flushing toilets.28 The neutropenic diet (also called a low-microbial diet) was originally developed to prevent immunocompromised cancer patients at risk for infection from normally harmless bacteria found in and on foods. Since then, the diet has been used to prevent the transfer of pathogens in food to any at-risk patients. There is no standardized neutropenic diet. The diet may restrict the types of foods eaten as well as the preparation methods. The most commonly restricted foods are fresh/raw fruits and vegetables, fruit juices, and raw eggs; the most common preparation method is to cook all foods thoroughly. To eliminate all potential sources of dietary pathogens, the patient should avoid the following foods:30 • Unpasteurized dairy products • Cheeses from delis • Cheeses with mold (e.g., blue, Roquefort, or gorgonzola) • Mexican-style soft cheeses (e.g., queso fresco or queso blanco) • Raw or undercooked meats, eggs • Meats or cold cuts from delis • Uncooked seafood (e.g., lox, smoked, jerky, or kippered) or pickled fish • Unwashed raw fruits and vegetables • Unpasteurized fruit and vegetable juices • Raw vegetable sprouts (e.g., alfalfa, mung bean) • Salads from delis • Salad dressings from the grocer’s refrigerator case • Raw or non-heat-treated honey • Raw grain products (e.g., raw oats) not baked or cooked • Unrefrigerated cream-filled pastry products (not shelf-stable) • Unroasted nuts or nuts in the shell • All miso products • Uncooked Brewer’s yeast • Untested and unboiled well water • Sun tea or yerba mate tea • All herbal and dietary supplements (without physician approval) While the neutropenic diet is still in

38 | OR TODAY | FEBRUARY 2019

use, its efficacy in preventing infections is being questioned. Few studies have been done that show patients on a neutropenic diet have fewer infections than those on a diet that is prepared following government food-safety guidelines.31,32 However, one study found increased infections among patients with HSCT given a neutropenic diet compared to patients with HSCT given an Academy of Nutrition and Dietetics-approved general hospital diet.32 A short review of the literature revealed no difference in the outcome based on whether the patient was given a neutropenic diet or a general diet with few restrictions.31 Until more evidence is available, it is important that neutropenic diets have the least number of food restrictions (without sacrificing safety) to ensure patients will follow the diet, there are no nutritional deficiencies from an overly restrictive diet, it does not cause food aversions, and it does not impair quality of life. Preventing fungal infections in patients who are severely immunosuppressed remains a challenge. When patients are severely immunosuppressed and isolated in a protective environment, nurses and healthcare providers play a key role in helping them understand the need to adhere to infection-control protocols that will reduce their exposures to pathogens in the environment. EDITOR’S NOTE: Connie C. Chettle, MS, MPH, RN, and Barbara BarzoloskiO’Connor, MSN, RN, CIC, previous authors of this CE activity, have not had an opportunity to influence this version. Luci Perri, MSN, MPH, RN, CIC, FAPIC, is an infection prevention consultant and owner of Infection Control Results in North Carolina. She travels throughout the country to help clients resolve infection prevention and control issues.

March 13, 2015. Accessed December 6, 2017. 2. Suleyman G, Alangaden GJ. Nosocomial fungal infections: epidemiology, infection control, and prevention. Infect Dis Clin North Am. 2016;30(4):1023-1052. doi: 10.1016/j. idc.2016.07.008. 3. Fungal diseases. Candida. Centers for Disease Control and Prevention Web site. https:// www.cdc.gov/fungal/diseases/candidiasis/ index.html. Updated August 7, 2017. Accessed December 6, 2017. 4. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):1198-1208. doi: 10.1056/NEJMoa1306801. 5. Strollo S, Lionakis MS, Adjemian J, et al. Epidemiology of hospitalizations associated with invasive Candidiasis, United States, 2002-2012. Emerg Infect Dis. 2016;23(1):7-13. doi: 10.3201/ eid2301.161198. 6. Calandra T, Roberts JA, Antonelli M, Bassetti M, Vincent JL. Diagnosis and management of invasive candidiasis in the ICU: an updated approach to an old enemy. Crit Care. 2016;20(1):125. doi: 10.1186/s13054-016-1313-6. 7. Fungal infections: Aspergillus statistics. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/fungal/diseases/aspergillosis/statistics.html. Updated November 14, 2015. Accessed December 6, 2017. 8. Hildalgo JA. Candidiasis. eMedicine Web site. http://emedicine.medscape.com/ article/213853-overview. Updated December 1, 2017. Accessed December 6, 2017. 9. Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1-e50. doi: 10.1093/cid/civ933. 10. Tsay S, Welsh RM, Adams EH, et al. Notes from the field: ongoing transmission of Candida auris in health care facilities — United States, June 2016-May 2017. MMWR Morb Mortal Wkly Rep. 2017;66(19):514-515. doi: 10.15585/mmwr. mm6619a7.

References

11. Vallabhaneni S, Kallen A, Tsay S, et al. Investigation of the first seven reported cases of Candida auris, a globally emerging invasive, multidrug-resistant fungus — United States, May 2013-August 2016. MMWR Morb Mortal Wkly Rep 2016;65(44):1234-1237. doi: 10.15585/ mmwr.mm6544e1.

1. Bains S. Candidiasis in emergency medicine. eMedicine Web site. http://emedicine.medscape.com/article/781215-overview. Updated

12. Candida auris. Centers for Disease Control and Prevention Web site. https://www.cdc. gov/fungal/diseases/candidiasis/candida-

WWW.ORTODAY.COM

auris.html. Updated November 17, 2017. Accessed December 6, 2017. 13. General information about Candida auris. Centers for Disease Control and Prevention Web site. https://www. cdc.gov/fungal/diseases/candidiasis/ candida-auris-qanda.html. Updated September 14, 2017. Accessed December 6, 2017. 14. Recommendations for treatment of Candida auris. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/fungal/diseases/ candidiasis/c-auris-treatment.html. Updated September 14, 2017. Accessed December 6, 2017. 15. Recommendations for identification of Candida auris. Centers for Disease Control and Prevention Web site. https:// www.cdc.gov/fungal/diseases/candidiasis/recommendations.html. Updated October 24, 2017. Accessed December 6, 2017. 16. Chowdhary A, Sharma C, Meis JF Candida auris: a rapidly emerging cause of hospital-acquired multidrug-resistant fungal infections globally. PLoS Pathog. 2017;13(5): e1006290. doi: 10.1371/journal.ppat.1006290. 17. Schelenz S, Hagen F, Rhodes JL, et al. First hospital outbreak of the globally emerging Candida auris in a European hospital. Antimicrob Resistance Infect Control. 2016;5:35. doi: 10.1186/s13756016-0132-5. 18. Candida auris: questions and answers for healthcare workers. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/fungal/diseases/ candidiasis/qa-healthcare-workers. html. Updated July 14, 2017. Accessed December 6, 2017. 19. Harman EM. Aspergillosis. eMedicine. http://emedicine.medscape.com/ article/296052-overview. Updated July 14, 2017. Accessed December 6, 2017. 20. Schmiedel Y, Zimmerli S. Common invasive fungal diseases: an overview of invasive candidiasis, aspergillosis, cryptococcosis, and Pneumocystis pneumonia. Swiss Med Wkly. 2016;146:w14281. doi: 10.4414/smw.2016.14281. 21. Jiang S. Immunity against fungal infections. Immunol Immunogenet Insights. 2016:8 3-6. doi: 10.4137/III.S38707. 22. Kourkoumpetis TK, Desalermos A, Muhammed M, Mylonakis E. Central nervous system Aspergillosis: a series of 14 cases from a general hospital and review of 123 cases from the literature. Medicine (Baltimore). 2012;91(6):328-336. doi: 10.1097/MD.0b013e318274cd77. 23. Patterson TF, Thompson III GR, Denning DW, et al. Practice guidelines for the diagnosis and management of WWW.ORTODAY.COM

Aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;63(4):e1-60. doi: 10.1093/ cid/ciw326. 24. Fungal infections: Candida infections of the mouth, throat, and esophagus. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/fungal/diseases/candidiasis/thrush/index. html. Updated August 4, 2017. Accessed December 6, 2017. 25. Marschall J, Mermel LA, Fakih M, et al. Strategies to prevent central lineassociated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):753771. doi: 10.1086/676533. 26. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections (2011). Centers for Disease Control and Prevention Web site. https://www.cdc. gov/infectioncontrol/guidelines/bsi/ index.html. Updated November 5, 2015. Accessed December 6, 2017. 27. Recommendations for infection control for Candida auris. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/fungal/diseases/candidiasis/c-auris-infection-control. html. Updated September 14, 2017. Accessed December 6, 2017. 28. Warris A, Verweij PE. Clinical implications of environmental sources for Aspergillus. Med Mycol. 2005;43(Suppl):s559-565. doi: 10.1080/13693780400025260. 29. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings (2007). Centers for Disease Control and Prevention Web site. https://www.cdc.gov/ infectioncontrol/guidelines/isolation. Updated October 31, 2017. Accessed December 6, 2017. 30. Diet guidelines for immunosuppressed patients. Fred Hutchinson Cancer Research Center Web site. http://www.fredhutch.org/content/ dam/public/Treatment-Suport/LongTerm-Follow-Up/HSC-Diet-Immunosuppressed-Patients-032508.pdf. Accessed December 6, 2017. 31. Trifilio S, Helenowski I, Giel M, et al. Questioning the role of a neutropenic diet following hematopoietic stem cell transplantation. Biol Blood Marrow Transplant. 2012;18(9):1385-1390. doi: 10.1016/j.bbmt.2012.02.015. 32. Garófolo A. Neutropenic diet and quality of food: a critical analysis. Revista Brasileira Hematologia Hemoterapia. 2013;35(2):79-80. doi: 10.5581/1516-8484.20130022.

CE390-60

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

Deadline Courses must be completed by 2/15/2020 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 (a Relias LLC company) 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. Relias LLC is approved by the California Board of Registered Nursing, provider # CEP13791.

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FEBRUARY 2019 | OR TODAY |

IN THE OR

continuing education

Clinical Vignette FOR CE390-60 Sharon is a new graduate RN who was hired to work in the ICU of a large urban hospital. She will be working with a mentor, an experienced ICU nurse, for six months before she has her own patients. Recently, a patient who had been in the ICU for nearly five weeks died of invasive candidiasis. The diagnosis was made after the patient’s death.

1 Sharon wanted to know why everyone in the ICU talked about methicillinresistant Staphylococcus aureus (MRSA) but never mentioned Candida. She asked, “Is Candida really a problem?” Her mentor told her: a. Nurses rarely see patients with Candida infections. b. Candida species account for only 1% to 2% of all hospital-acquired infections.

c. Candida is the most common cause of bloodstream infections. d. Candidiasis is easily treated, and the mortality rate is low.

2 Sharon asked about the risk factors for invasive candidiasis. She was told: a. A prolonged stay in the ICU, unfiltered air, and urinary catheters b. Construction dust, broad-spectrum antibiotics, and total parenteral nutrition

c. Indwelling medical devices, prolonged immunosuppression, and corticosteroid use d. COPD, potted plants, and flowers and contaminated water

haron asked if any other fungal infections caused invasive disease in 3 S

hospitalized patients. Her mentor told her the two most important fungal infections that cause invasive disease in hospitalized patient are:

a. Candida and Aspergillus b. Cryptococcus and blastomycosis

c. Onychomycosis and coccidioidomycosis d. Histoplasmosis and tinea pedia

fter Sharon spent some time reading about invasive Candida and Aspergillus, her mentor 4 A

decided to quiz her. She asked which statement about aspergillosis and candidiasis is TRUE?

a. Infections with Aspergillus nearly always occur from an overgrowth of the fungi in the GI tract. b. The mortality rate for neutropenic patients with invasive Aspergillus infection is 10%.

c. In one study, 2% of healthcare workers had Candida strains on their hands. d. Candida bloodstream infections have the highest mortality rate of all bloodstream infections.

Clinical VignettE ANSWERS 1. Answer: C. Candida species account for about 6% of all hospital-acquired infections, more than 70% to 90% of fungal infections, and 22% of bloodstream infections, making Candida the most frequently isolated organism in bloodstream infections. 2. Answer: C. The two major risk factors for developing invasive Candida infections are prolonged immunosuppression or an exposure to an ICU environment. In the ICU, widespread use of broad-spectrum antibiotics and indwelling medical devices is especially favorable for the growth of Candida. Mechanical ventilation greater than three days is also a risk factor for Candida infections. 3. Answer: A. The two most important species of fungi that cause invasive disease in hospitalized patients are Candida and Aspergillus. Both are associated with high morbidity, high mortality, and a significant use of medical resources. 4. Answer: D. Candida bloodstream infections have the highest mortality rate of all bloodstream infections, and for invasive disease (disseminated candidiasis) the mortality rate is similar to that of septic shock, 40% to 60%.

40 | OR TODAY | FEBRUARY 2019

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KEEPING UP WITH THE

ASCQR PROGRAM BY DON SADLER

n 2012, the Centers for Medicare and Medicaid Services (CMS) established a uniform quality reporting system that enabled ambulatory surgery centers (ASCs) to demonstrate their performance on several quality measures developed based on years of rigorous review and testing. This program is referred to as the Ambulatory Surgical Center Quality Reporting (ASCQR) program. Each year, when CMS issues updates to its final payment rule for ASCs and hospital outpatient departments (HOPDs) for the coming year, it includes updates to the data collection, data submission and program administration requirements ASCs need to be in compliance with Medicare’s ASCQR reporting program. ASCs that do not meet these requirements can experience future reductions in their Medicare reimbursement. CMS released its final 2019 payment rule for ASCs and HOPDs on November 2, 2018.

The Specs Manual “In 2012, we asked CMS to give us a document that was easy to read and use,” says Gina Throneberry, RN, MBA, CASC™, CNOR, the Director of Education and Clinical Affairs for the Ambulatory Surgery Center Association (ASCA). The result was a CMS ASC Quality Reporting Program Measures Specification Manual, or the Specs Manual for short. “This is the guide for the program,” says Throneberry. “I highly recommend that ASCs read the specs manual thoroughly.”

The Specs Manual can be downloaded under the ASC tab at www.qualitynet.org. Included in the manual are measure specifications, data collection and submission, and Quality Data Codes (QDC). There have been many versions of this manual since 2012, says Throneberry, so it’s critical to make sure you’re using the right one. Measures that are suspended remain in the CMS ASCQR program and could possibly return in the future. Measures that are deleted no longer remain in the program. The final payment rule for 2019 removed a total of two quality reporting measures and suspended four measures across calendar years 2020 and 2021 for payment determinations. “Remember that collecting, reporting and payment determination is a two-year process,” says Throneberry. Specifically, ASC-8 and ASC-10 will be removed for these two calendar years. “However, you should make sure this data isn’t required by your state,” says Throneberry. Meanwhile, to qualify for a full payment update in 2020, ASCs must report the data collected in 2018 on measures ASC-9 and ASC-10 by May 15, 2019. ASC-11 has been voluntary for several years and will remain so, while implementation of ASC 15a-e (OAS CAHPS Survey measures) will continue to be delayed. And CMS is changing the reporting period for ASC-12 from one to three years. There is no data submission or reporting required from the ASC for ASC-12. Data is pulled by CMS from the Medicare Fee For Service administrative claims that were billed by the ASC starting January 1-December 31, 2016 and subsequent years.

In an interview published on the ASCA

website in November, ASCA CEO William Prentice said that the changes included in this year’s final payment rule are among the most significant he has seen in his eight years with ASCA. FEBRUARY 2019 | OR TODAY |

Data collection for ASC-1, ASC-2, ASC-3 and ASC-4 is being suspended starting on January 1, 2019, until further rulemaking. “Also, ASCs no longer have to report data for ASC-5, ASC-6 and ASC-7,” says Throneberry. “However, I recommend still collecting this data internally in case it’s needed for some other project or survey, such as an internal quality assurance performance improvement program or if you participate in benchmarking surveys,” she adds. “This is still considered a best practice.” And starting this year, ASCs must begin reporting information they began collecting in 2018 on two new measures: ASC-13 and ASC-14.

Significant Changes This Year In an interview published on the ASCA website in November, ASCA CEO William Prentice said that the changes included in this year’s final payment rule are among the most significant he has seen in his eight years with ASCA. “I would say the changes demonstrate greater recognition of the quality and value that ASCs provide than we have seen in any previous rulemaking,” said Prentice. For example, the changes include a decision to update ASC payments using the hospital market basket inflation factor for calendar years 2019 through 2023. “This is a much more realistic indicator of rising costs in the ASC space than what CMS has been using,” said Prentice. “We have fought for this change over the last decade and appreciate that it has been adopted.” Prentice explains that changes in annual inflationary adjustments for ASCs will now be based on the hospital market basket, instead of the Consumer Price Index for All Urban Consumers (CPI-U). “Since ASCs use the same staff, services and supplies as HOPDs, it only makes sense to apply the same inflation rate for our yearly updates,” said Prentice. “Under the final rule, ASCs will see, on average over all covered procedures, an effective update of 2.1 percent,” he added. Other new policies in the final payment rule encourage the migration of device intensive procedures to ASCs and allow for several new cardiac procedures in the ASC setting.

44 | OR TODAY | FEBRUARY 2019

“These changes are positive and beneficial for ASCs and the patients they serve, and we are encouraged to see CMS adopting these policies,” said Prentice. More specifically, CMS reduced the threshold definition of device intensive procedures in ASCs from 40 percent to 30 percent. “So if the device portion of the overall procedure equals 30 percent or more of the total cost of the procedure in the HOPD setting, the total device cost will be included in the reimbursement rate when the procedure is performed in an ASC,” Prentice explained. “This decision results in a net increase of 124 new device intensive procedures that ASCs can now afford to provide for Medicare beneficiaries for the first time,” he added. As a result, the approved list will expand from 153 to 277 device intensive procedures in 2019. “This is a policy change we have been advocating for over the past several years to encourage migration of these procedures into ASCs,” said Prentice.

ASCQR program

Accounting for Surgery-Like Procedures According to Prentice, CMS also revised its definition of “surgery” to account for certain “surgery-like” procedures that are assigned codes outside the Current Procedural Terminology (CPT) surgical range. “This change allowed CMS to add the 12 cardiac catheterization procedures that were included in the proposed rule to the ASC covered procedures list,” said Prentice. “Based on feedback from stakeholders, CMS also added

I would say the changes demonstrate greater recognition of the quality and value that ASCs provide than we have seen in any previous rulemaking. -William Prentice WWW.ORTODAY.COM

Gina Throneberry, RN, MBA, CASC™, CNOR, the Director of Education and Clinical Affairs for the Ambulatory Surgery Center Association (ASCA)

However, I recommend still collecting this data internally in case it’s needed for some other project or survey, such as an internal quality assurance performance improvement program or if you participate in benchmarking surveys. This is still considered a best practice.

-Gina Throneberry five additional procedures that are often performed alongside those codes.” There is also a provision in the final payment rule that addresses payment for non-opioid pain management therapy. Prentice says this is a result of President Donald Trump’s emphasis on responding to the opioid epidemic in America. “Past payment policy served as an impediment to using non-opioids for post-surgical pain,” Prentice said. “This provision addresses our concerns by allowing ASCs to get paid for non-opioid pain relief drugs when used in a surgical procedure.”

Education is Crucial Because “the devil is in the details” when it comes to Medicare quality reporting compliance, Prentice recommends that ASCs educate themselves thoroughly on the final 2019 payment rule. ASCA has prepared a free webinar hosted by Throneberry and ASC Quality Collaboration Executive Director Donna Slosburg that answers common questions about the final payment rule. The webinar is now available on demand at https:// www.ascassociation.org/educationevents/upcomingevents/webinars. “I recommend that all ASCs listen to this webinar to make sure they are doing everything needed to comply,” said Prentice.

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William Prentice, ASCA CEO FEBRUARY 2019 | OR TODAY |

S P O T L I G H T

O N :

J O Nia I Garc

B Y M AT T S K O U FA L O S

Like many working nurses, Joni Garcia kicked off her career in health care at an early age – sort of. It all started when she was just six years old. Her older brother had come down with a cold, and Garcia was tasked with an important chore in his recovery.

then your clinical instructor would sign off on your credentials,” Garcia said. “For your junior year, you had a total of 80 OR cases that you had to finish before you could enroll for your senior year. When I was talking to the nurses here, I was like, ‘You guys didn’t do that?’ ” Garcia first visited the United States as a tourist in 1999. After she decided “My mom’s like, ‘Can you get your brother to pursue the next stage of her nursing career in America, she completed her U.S. some water?’ and I was like, ‘Oh my god, nursing boards, and was sponsored by a I’m going to be a nurse when I grow up,’” Philadelphia, Pennsylvania-based home she laughed. “I thought I was so cool.” care company, Visiting Nurse Group. After Whether it was an early moment of she was eased into basic home care cases to prescience or not, Garcia indeed continstart her practice, Garcia’s confidence grew ued into a nursing career. Growing up in as her assignments increased in complexity. the Philippines, she completed a rigorous When her contract was up, Garcia education track at Far Eastern University caught on with a different home care comin Manila; one that prepared her for the pany before finding a perioperative orienintensity of her later career in the United tation at Children’s Hospital of PhiladelStates. Instructors wouldn’t advance stuphia (CHOP). While making the rounds dents to the next year of their bachelor’s program without hitting strict benchmarks. through various surgical disciplines, Garcia discovered an interest in orthopedics. Garcia remembers summers spent trying “I wanted to learn how to do the to complete every assignment before the spines,” she said. “The whole entire sumnext semester’s enrollment began. mer, they put me in a spine room every “Before you were graduated to your junior year, you had to birth 20 babies, and day to get proficient.”

46 | OR TODAY | FEBRUARY 2019

RN, BSN, CNOR

Garcia has been with CHOP for 12 years. Her current assignment is as a “breaker,” working a 12-hour shift in which “you get thrown anywhere and everywhere,” relieving surgical nurses for their mandatory breaks. “Whatever the nurse is supposed to be doing in those next 15 minutes, you take over,” she explained. “Then, after the 15 minutes, they came back, and you report back to them – ‘I did your sponges,’ ‘I added an instrument tray,’ ‘I added so many sutures.’ Then, on to the next one.” In addition to being a pediatric teaching hospital, CHOP is a Level I trauma center, which means Garcia is accustomed to treating patients with complicated chronic medical conditions as well as those with injuries from accidents or other violence. The difficulty and variety of cases she’s seen in her tenure there have given Garcia a level of unflappability that makes her perfectly suited to the breaker role. “I’m at a point where I’ve done everything except for a liver transplant or a heart transplant,” she said. A high-water mark came in 2015, when Garcia participated in the first

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From the Philippines to Philadelphia,

pediatric double-hand transplant in the world. She recollects that surgery, a tightly orchestrated series of procedures coordinated among four teams, one for each of the donor and recipient hands. The entire operation was completed within nine hours, and today, the patient, nine-year-old Zion Harvey of Baltimore, has gained the independence of two functioning limbs, thanks to their work. “The last update we had last year, he pitched a baseball at the Baltimore Orioles game,” Garcia said. In the decade-plus of work she’s done at CHOP, Garcia has left the area for only one assignment: an 18-month stint as a travel nurse in Houston, Texas. In that time, she worked at four different hospitals in the Houston metro area, and focused on adult patients, a contrast to the 12 years she’d spent working in a pediatric environment. “I thought, ‘There’s so much to learn,’ ” she said. “I truly learned a lot more than what I knew before I’d started traveling. I realized there were things we could be doing differently to improve our workflow.” To Garcia, continuous education is the hallmark of a nursing professional, and at a teaching hospital like CHOP,

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her values are aligned with that of the organization. She said the environment is also one in which clear, easy communication is welcomed and even encouraged; one where surgeons are not intimidated by the suggestions of a colleague, and where help isn’t far away when it’s needed. “Good OR nurses have the ear that you could be doing something else, and part of you is listening out for the anesthesiologist,” Garcia said. “You always have to be on top of your game. Even if I’m doing something, you hear the monitors, or you let the surgeon know. You’re the patient’s advocate.” She also points out that listening is a two-way street. For as much as she might have a contrary perspective to that of the doctors in the room, Garcia is prepared to accept constructive criticism herself. She said the environment at CHOP supports such effective communication, in part because the length of tenure she’s enjoyed there makes it easy to stay. “There’s a lot of lifers at CHOP,” Garcia said. “We’ve worked with these surgeons for years. They know you, they know what you can do, and they’ll listen to you. If they need help, people will come in.”

Joni Garcia loves being a nurse and an advocate for patients.

FEBRUARY 2019 | OR TODAY |

OUT OF THE OR fitness

Is Your Food Hurting or Helping You? By Miguel J. Ortiz he food industry and our education around food hasn’t really evolved to truly heal us like it should. When all physicians embark on their journey through medicine they all learn a very simple quote. “Let thy medicine be thy food and let thy food be thy medicine,” Hippocrates. Yet, we don’t really use food for medicine.

This is something the population has started understanding more, especially since long-term pharmaceutical medication has been one of the top killers. A recent Johns Hopkins study claims more than 250,000 people in the U.S. die every year from medical errors. Other reports claim the numbers to be as high as 440,000. And some long-term medication kills more than cardiovascular disease. We have less people going to the doctor and more people trying to take care of themselves. Whether it be through a good ole remedy our ancestors passed down or something as simple as fasting and getting plenty of rest. But, how do we do that with all the stress we have in our life? “We heal ourselves by what we put in our body,” says Dr. Sebi. I have studied many diets including

48 | OR TODAY | FEBRUARY 2019

the Keto, paleo diet and even juicing for short periods of time. The number one diet that very little people look into, yet it’s the most affective at fighting disease, is the Alkaline diet. It’s a proven fact that no disease, including cancer, can survive in an alkaline environment. So why aren’t more people following it? It’s because of what a person has to give up. This way of eating rejuvenates and cleanses cells, fuels the body and helps eliminate unnecessary waste. So even though it seems ideal our current society would need to consider giving up anything that can cause acidity. The human body has an optimal pH level of about 7.365 anything less than that is considered more acidic anything higher is more alkaline. Food like raw broccoli, raw cabbage, organic cucumber are all about a 10.0 pH level and on the other side you have the more acidic foods like coffee, pasta, white bread, beef, pork and processed foods which are all under 4.0 pH. Sodas fall below 3.0 pH. A very important thing to consider is the balance that is necessary to keep you healthier and don’t look so deep into exact pH levels. Counting calories has been a puzzle since its inception and has never considered what the calories are once food is cooked. So, let’s not worry about

the exact numbers here either. I think we all can understand when we are full. Having that awareness in the body in also important, but will be discussed another time. For now, worry about if your food is more acidic or more alkaline and eat accordingly. Start making smarter choices like using soft drinks and sodas as a treat and not a weekly or daily item to have. Add more fiber to your diet, most alkaline items tend to be greens and quality fiber. Do less cooking of food and eat more raw foods. Microwaves especially cause food to become more acidic by the way it works to heat the food. It is changing the food’s molecular compounds ultimately changing the pH level. Yes, it’s a different taste but it saves you time if you understand how to prep properly. This journey into a healthier lifestyle isn’t for the faint hearted, but the moment you put good food in your mouth is the moment your body starts healing itself. Let your food be your medicine. Miguel J. Ortiz is a personal trainer in Atlanta, Georgia. He is a member of the National Personal Trainer Institute and a Certified Nutritional Consultant with more than a decade of professional experience. He can be found on Instagram at @migueljortiz. WWW.ORTODAY.COM

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OUT OF THE OR health

Sign Up for Happiness 101! By Marilynn Preston ould you be surprised to learn that one of the most popular college courses in America teaches students how to be happy? Probably not.

Most adults discover that you can be crazy rich, drive the biggest Tesla, take a luxury vacation that costs $4,500 a night – breakfast not included – but if inside you’re feeling miserable and depressed and unhappy, what good is it? Welcome to Professor Laurie Santos’ wildly popular course at Yale University called “Psychology and the Good Life.” I haven’t taken it yet, but as a dedicated student of positive psychology, I’ve studied the research for years, including a recent overview of Santos’ work by Adam Sternbergh called “How To Be Happy.” The article was published this summer in New York Magazine, now available online at The Cut, and is well worth reading. “College students are much more overwhelmed, much more stressed, much more anxious, and much more depressed than they’ve ever been,” says Santos. Yeah ... so who isn’t? We are all living through destabilizing, demoralizing times, and the toll it’s taking on our collective well-being is palpable. Students are suf-

50 | OR TODAY | FEBRUARY 2019

fering – 52 percent are feeling hopeless, Sternbergh reports – and so is America at large, and I do mean large. In the last 10 years, the United States has dropped more than 15 places (!!!) in the World Happiness Report issued by the U.N. every year. In the latest one, we’ve sunk to No. 18, well behind Norway (No. 1) and Australia and Sweden (tied for No. 10). Why is this happening? “Rising inequality, corruption, isolation and distrust” are some of the reasons that U.N. adviser Jeffrey Sachs cites in his analysis of America’s slide into despair: “Trust in government has plummeted to the lowest level in modern history.” On that happy note, let’s take a deep breath and a deeper dive into some of Santos’ course material and see what we can do in real time, in practical ways, to be happier.

Establish a baseline To begin, ask yourself: How happy are you, right now? One reliable and easy way to determine that, if you dare, is to do what every student who takes Santos’ course must do: Take a free online test called the Authentic Happiness Inventory, courtesy of the University of Pennsylvania’s most positive psychologist, Dr. Martin Seligman. (The Google will

happily take you there.) Don’t judge the number you get. Accept it as your starting point, and know that you can evolve, improve and prosper over time, if you’re willing to change a few behaviors and beliefs.

What we think we know is wrong Santos’ course is evidence-based, and there’s plenty of evidence to prove that high achievement and good grades don’t lead to sustained well-being. Neither does more money (after a certain level of comfort), a different home or job or a long luxurious vacation. Your mind may be telling you that all these things will make you happier, but your mind is playing tricks on you, Santos explains, citing the work of Sonya Lyubomirsky, the esteemed psychologist and author of “The How of Happiness.” (I hope you’re taking notes.)

What are true sources of happiness? “Happy people devote time to family and friends,” Sternbergh reports, summing up Santos’ research into the habits most consistent in happy people. “They practice gratitude. They practice optimism. They are physically active. They ‘savor life’s pleasures and try to live in the present moment,’ as Lyubomirsky puts it.”

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TRIM 4.5”

All of this is revealed to Yalies in the course’s second lecture. The remaining 19 lectures are devoted to scientifically tested strategies to actively improve students’ well-being by doing things that rewire their brains. In her syllabus, Santos calls those behaviors “course re-wirements.” They include exercising (of course!), keeping a daily gratitude journal, practicing meditation, valuing your time over money, being optimistic and getting at least seven hours of sleep for three days in a row. Oh, no! We’re only getting started ... and class is over. Don’t worry. My own well-being depends on coming back to this material again and again. Meanwhile, check out Laurie Santos’ course on “The Science of Well-Being,” available from Coursera. “Why do we think we want salary and more stuff,” Professor Santos asks us all, “when ultimately, it doesn’t matter?”

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– Marilynn Preston is the author of “Energy Express,” America’s longestrunning healthy lifestyle column. For more on personal well-being, visit www.MarilynnPreston.com.

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OUT OF THE OR nutrition

Turn Up For Turnips! By Lori Zanteson oday’s turnips are all the rage in farm to table restaurants and are enjoyed for their subtly sweet flavor and nutrient density.

The folklore Despite a history as peasant food in ancient times, and later a reputation as the source of dinnertime revolt for many children, this bulbous root deserves a say – it has plenty to bring to the table! In fact, Roman philosopher Pliny the Elder wrote that the turnip was one of the most important vegetables of his day. Not only was it used as farm animal fodder, but it could be left in the ground (or later, the cellar) until the next harvest, a safeguard against human famine. Ancient Greeks and Romans believed turnips had healing powers – they made a syrup from turnips to cure whooping cough and the common cold.

The facts The turnip (Brassica rapa) is a cruciferous root vegetable in the mustard family, along with cauliflower, cabbage and Brussels sprouts. There are over 30 varieties of turnips, which differ in size, taste and use, includ-

52 | OR TODAY | FEBRUARY 2019

ing small “baby” specialty turnips. Topped by edible greens (similar to mustard greens), the spherical root averages three inches diameter, is white below the earth with a kiss of purple, red or green where exposed to the sun, and tapers into a thin taproot. A 1-cup serving has only 34 calories, yet packs 12 percent DV (Daily Value, based on 2,000 calories/day) of dietary fiber, 30 percent DV of vitamin C, and plenty of powerful health promoting phytonutrients.

The findings One such compound in cruciferous vegetables, like turnips, is brassinin, which has been shown in lab studies to kill colon cancer cells (International Journal of Oncology, 2012). Among cruciferous vegetables, turnip sprouts were shown to have among the highest concentrations of glucosinolates, a compound known for its anti-cancer activity (Journal of Agricultural and Food Chemistry, 2012). In addition, eating high fiber foods, such as turnips, is associated with lower colorectal cancer death (JAMA Oncology, 2018). Lastly, a study published in the Journal of Epidemiology suggests higher dietary

intakes of antioxidant vitamins, like the vitamin C in turnips, may reduce risk of death from any cause in middle aged Japanese women.

The finer points Turnips are available all year, but they’re best eaten when they’re young, small, tender and sweet. Choose smooth, firm bulbs that are heavy for their size, and if greens are attached, be sure they’re bright and fresh. Refrigerate bulbs, wrapped in plastic, for up to two weeks. Remove skin, greens and taproot before slicing or grating small bulbs raw into salads and slaws for added zing and crunch, or slicing or cubing them to boil, sauté, bake or steam. Try turnips mashed or added to soups, layered into a comforting gratin, or combined with carrots, parsnips, sweet potatoes and hearty squash in a colorful veggie roast. – Environmental Nutrition is the award-winning independent newsletter written by nutrition experts dedicated to providing readers up-to-date, accurate information about health and nutrition in clear, concise English. For more information, visit www. environmentalnutrition.com. WWW.ORTODAY.COM

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kills and knowledge alone are not enough to ensure the consistent level of staff engagement needed to achieve patient satisfaction and clinical outcomes necessary for success in the 21st-century. How we treat each other is directly related to how well we engage our patients and their families. Positive attitudes and collegial behaviors are vital to realizing strategic benchmarks and goals.

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FEBRUARY 2019 | OR TODAY |

OUT OF THE OR

Recipe

recipe

Thai Carrot Soup

INGREDIENTS:

• 1 teaspoon vegetable oil • 4 cups coined carrots, about 4 to 5 carrots • 1 1/2 cups diced onion • 1 tablespoon chopped ginger • 1 tablespoon chopped garlic • 1 teaspoon red Thai curry paste • 2 cups vegetable stock or water • 1 cup coconut milk • 1/2 star anise (optional) • 2 teaspoons soy sauce • 2 teaspoons sugar (optional) • 1/2 lime, juiced

the

54 | OR TODAY | FEBRUARY 2019

Kary Osmond is a Canadian recipe developer and former television host of the popular daytime cooking show “Best Recipes Ever.” Learn more at www.karyosmond.com.

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OUT OF THE OR recipe

Warm up with a bowl of Thai carrot soup lended soups are perfect when it’s cold outside. And I especially love soups with a hint of spice to tickle the throat. Not only is this soup simple to make, but it also freezes well, kids love it, and it goes well with one of my favorite foods: toast! Best of all, if you have a bunch of carrots in your fridge, this is a great way to use them up. When experimenting with Thai recipes your goal is to achieve a balance between sweet, sour, spicy and salty. The sweet in this recipe comes from two ingredients: coconut milk and carrots.

The sour comes from lime juice (not only does it add a sour note, it also adds a delicate lime fragrance). The spice is added through the red Thai curry paste. The saltiness in Thai food usually comes from fish sauce, but because I’m keeping this recipe plant-based, I’m using soy sauce instead. To tickle your nose, I’ve added something special: star anise. Though it’s not essential, I do recommend it for the sweet fragrance; just be sure to remove it before you blend the soup.

Thai Carrot Soup Serves 4 to 5 1.

Heat a large pot over medium heat. Add oil, carrots, onion, ginger, garlic and curry paste. Cook covered, and stir often until onions have started to soften, about 5 minutes. 2. Add vegetable stock or water, coconut milk and star anise (if using). Bring to a boil, cover, reduce heat to low, and simmer until carrots are very tender, about 35 to 45 minutes. 3. Allow soup to cool slightly, remove star anise, and blend using hand blender until smooth. If soup is too thick, add water, 1/4 cup at a time, until desired consistency. Season with soy sauce and sugar. Garnish with lime juice. Thai carrot soup tips • The sweeter your carrots, the sweeter this soup will be. If your carrots are lacking in that department, you can bump up the sweetness at the end with a little sugar; just a touch will do. • Cook the carrots until you can mash them with the back of a fork, this will make for a smooth soup. • All Thai curry pastes are different, with different heat levels. My suggestion is to start this recipe with 1/2 to 1 teaspoon of curry paste. If you find you want more flavor and heat, you can always add more. If you want even more spice, add some chopped red Thai chili. But be careful; those tiny chilies pack a lot of heat. • The flavor of lime will dissipate with heat, so add it just before you serve it. • If you don’t have a hand blender, you can use a food processor or traditional blender. Cool the soup first; then blend it in batches until smooth, adding water if necessary.

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FEBRUARY 2019 | OR TODAY |

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The News and Photos

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OUT OF THE OR pinboard

‘The Vegan Starter Kit’ Provides a Fast Track to Health If you are looking to lose weight and get healthy you will have no trouble sticking to it with the help of Neal Barnard’s new book, “The Vegan Starter Kit.” Vegan diets have been shown to reverse heart disease and diabetes and to cause impressive weight loss without calorie-counting. The book, which hit shelves December 24, gives readers all the tools they need to get started: delicious recipes, answers to frequently asked questions, guidelines on ensuring complete nutrition, quickreference charts for sources of calcium and protein, tips for modifying recipes and more. Barnard’s research, funded by the U.S. government, established the power of vegan diets for diabetes, and he is often called on by news programs and celebrities for nutrition advice. Many are looking to adopt a more healthful diet but may have questions, like: How do I plan a vegan meal? Is protein an issue? Which are the best choices at restaurants or if I’m traveling? Barnard has the answers to these questions and more.

“The Vegan Starter Kit” also includes information on healthy eating in childhood, pregnancy, and other stages of life, and a complete set of basic meals, holiday feasts, snacks, among many other tips. “Dr. Barnard makes a compelling case as to why all of us should ‘test drive’ a vegan diet. His guidebook is straightforward and simple to follow ... as easy to digest as a plant-based lifestyle. All in all, a delicious read,” says journalist and television personality Meredith Vieira. “We’ve known Neal Barnard for years as a leader in the plant-based revolution. His new book makes it so easy to start your plant-based journey that we’re recommending ‘The Vegan Starter Kit’ to everyone we meet who’s vegan curious or just interested in good health, better energy levels, and a longer, more vibrant life,” say Suzy Amis Cameron and James Cameron. Going vegan is expected to be one of the biggest health trends in 2019. Vegan diets rose in popularity by 600 percent between 2014 and 2017, while Google

More Adults, Children Use Yoga and Meditation

in Americans’ use of specific practices, 2017 survey data were compared with a version of the survey fielded in 2012. “The 2017 NHIS survey is the most current and reliable source of information on the use of specific complementary health approaches by U.S. adults and children. The survey data suggest that more people are turning to mind and body approaches than ever before, and the research we support at NCCIH is helping to determine the impact of those approaches on health,” said David Shurtleff, Ph.D., Acting Director of NCCIH. Survey highlights for adults: • Yoga was the most commonly used complementary health approach among U.S. adults in 2012 (9.5 percent) and 2017 (14.3 percent). The use of meditation increased more than threefold from 4.1 percent in 2012 to 14.2 percent in 2017. • The use of chiropractors increased from 9.1 percent in 2012 to 10.3 percent in 2017. • In 2017, women were more likely to use yoga, meditation, and chiropractors in the past 12 months than men.

Over the past five years, more Americans of all ages are rolling out their yoga mats and meditating. A large nationally representative survey shows that the number of American adults and children using yoga and meditation has significantly increased over previous years and that use of chiropractic care has increased modestly for adults and held steady for children. The complementary health questionnaire was developed by the National Center for Complementary and Integrative Health (NCCIH), part of the National Institutes of Health, and by the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS). The complementary health questionnaire is administered every five years as part of the National Health Interview Survey (NHIS), an annual study in which thousands of Americans are interviewed about their health- and illnessrelated experiences. To identify trends

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searches for the term vegan recently reached an all-time high. Consumer demand for plant-based products, meat alternatives and nondairy milks is also growing. For those looking for more resources to get started on a vegan diet, Dr. Barnard is also featured in the 21-Day Vegan Kickstart, a free online program and app, available on iTunes and Google Play, featuring 21 days of recipes, meal plans, cooking tips and nutrition information.

• Non-Hispanic white adults were more likely to use yoga, meditation, and chiropractors than Hispanic and nonHispanic black adults. Survey highlights for children: • The percentage of children aged 4-17 years who used yoga in the past 12 months increased significantly from 3.1 percent in 2012 to 8.4 percent in 2017. • Meditation increased significantly from 0.6 percent in 2012 to 5.4 percent in 2017. • There was no statistically significant difference in the use of a chiropractor between 2012 and 2017 (3.5 percent and 3.4 percent, respectively). • In 2017, girls were more likely to have used yoga during the past 12 months than boys. • In 2017, older children (aged 12-17 years) were more likely to have used meditation and a chiropractor in the past 12 months than younger children (aged 4-11 years). Read more about the survey at https:// nccih.nih.gov/research/statistics/ NHIS/2017.

FEBRUARY 2019 | OR TODAY |

INDEX

advertisers

Alphabetical AIV Inc.…………………………………………………………………13

Innovative Medical Products………………………… BC

OR Today Webinar Series…………………………………41

Alco Sales Service, Co.………………………………………19

Jet Medical Electronics Inc………………………………51

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

ASCA……………………………………………………………………19

MAC Medical, Inc……………………………………………… 26

Soma Technology………………………………………………15

Avante Patient Monitoring……………………………… 24

MD Technologies inc.………………………………………IBC

TBJ Incorporated…………………………………………………31

BD…………………………………………………………………………17

Microsystems……………………………………………………… 5

TIDI Sterile-Z…………………………………………………21,23

C Change Surgical……………………………………………… 9

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

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

OR Today Live…………………………………………………… 49

categorical ANESTHESIA

HOSPITAL BEDS/PARTS

REPROCESSING STATIONS

ASSET MANAGEMENT

INFECTION CONTROL

RESPIRATORY

Soma Technology………………………………………………15 Microsystems……………………………………………………… 5

ASSOCIATION

ASCA……………………………………………………………………19

C-ARM

Soma Technology………………………………………………15

CARDIAC PRODUCTS

Alco Sales Service, Co.………………………………………19 Alco Sales Service, Co.………………………………………19 Healthmark Industries Company, Inc.…………… 4 Ruhof Corporation…………………………………………… 2,3 TBJ Incorporated…………………………………………………31 TIDI Sterile-Z…………………………………………………21,23

INSTRUMENT STORAGE/TRANSPORT

C Change Surgical……………………………………………… 9 Jet Medical Electronics Inc………………………………51

TIDI Sterile-Z…………………………………………………21,23 Instrument Tracking Microsystems……………………………………………………… 5

CARTS/CABINETS

MONITORS

Alco Sales Service, Co.………………………………………19 Healthmark Industries Company, Inc.…………… 4 MAC Medical, Inc……………………………………………… 26 TBJ Incorporated…………………………………………………31

CONFERENCE

OR Today Live…………………………………………………… 49

CS/SPD

MD Technologies inc.………………………………………IBC Microsystems……………………………………………………… 5

DISINFECTION

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

DISPOSABLES

Alco Sales Service, Co.………………………………………19

ENDOSCOPY

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

FALL PREVENTION

Alco Sales Service, Co.………………………………………19

GENERAL

AIV Inc.…………………………………………………………………13

Avante Patient Monitoring……………………………… 24 Soma Technology………………………………………………15

OR TABLES/BOOMS/ACCESSORIES

Innovative Medical Products………………………… BC Soma Technology………………………………………………15

ONLINE RESOURCE

OR Today Webinar Series…………………………………41

OTHER

AIV Inc.…………………………………………………………………13

PATIENT DATA MANAGEMENT

Soma Technology………………………………………………15

SAFETY

Healthmark Industries Company, Inc.…………… 4 TIDI Sterile-Z…………………………………………………21,23

SINKS

TBJ Incorporated…………………………………………………31

SKIN PREPARATION

BD…………………………………………………………………………17

STERILIZATION

Healthmark Industries Company, Inc.…………… 4 TBJ Incorporated…………………………………………………31

SURGICAL

MD Technologies inc.………………………………………IBC Soma Technology………………………………………………15 TIDI Sterile-Z…………………………………………………21,23 Surgical Instrument/Accessories C Change Surgical……………………………………………… 9 Healthmark Industries Company, Inc.…………… 4

TELEMETRY

MAC Medical, Inc……………………………………………… 26

AIV Inc.…………………………………………………………………13 Avante Patient Monitoring……………………………… 24

PATIENT MONITORING

TEMPERATURE MANAGEMENT

AIV Inc.…………………………………………………………………13 Avante Patient Monitoring……………………………… 24 Jet Medical Electronics Inc………………………………51

POSITIONING PRODUCTS

Innovative Medical Products………………………… BC

REPAIR SERVICES

Avante Patient Monitoring……………………………… 24 Jet Medical Electronics Inc………………………………51 Mobile Instrument Service & Repair……………… 6 Soma Technology………………………………………………15

SAVE THE DATE! AUGUST 18-20, 2019 • LAS VEGAS, NV ORTODAYLIVE.COM 58 | OR TODAY | FEBRUARY 2019

TBJ Incorporated…………………………………………………31

C Change Surgical……………………………………………… 9 MAC Medical, Inc……………………………………………… 26

WARMERS

MAC Medical, Inc……………………………………………… 26

WASTE MANAGEMENT

MD Technologies inc.………………………………………IBC TBJ Incorporated…………………………………………………31

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