OR Today June 2019 by MD Publishing

INFECTION CONTROL PRODUCT FOCUS

CE ARTICLE C. DIFFICILE

OUT OF THE OR KINHIN

COMPANY SHOWCASE MEDLINE

JUNE 2019

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REDUCING

HAIs SSIs AND

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OR TODAY | June 2019

contents

features

REDUCING HAIs AND SSIs Despite the attention focused on healthcare associated infections (HAIs) and surgical site infections (SSIs) in recent years, the number of infections occurring remains high. Experts weigh in on ways to prevent these infections.

According to market reports, the infection control market is expected to eclipse $25 billion in the next decade. OR Today shares some products and solutions that can help health care facilities achieve infection control goals in the coming years.

The number of cases of nosocomial Clostridium difficile, as well as the proportion of cases with severe and fatal complications, has been increasing. Armed with knowledge, health care professionals can help meet the challenge of fighting this difficult pathogen.

One technique to reduce the likelihood of an SSI, as part of an overarching SSI prevention strategy, is to cleanse the incision site prior to surgery in order to reduce the microbial burden on the skin. Medline Industries Inc. now offers ReadyPrepâ&#x201E;˘ CHG Cloth to address SSIs.

PRODUCT FOCUS: INFECTION CONTROL

CE ARTICLE: C. DIFFICILE

COMPANY SHOWCASE: MEDLINE

OR Today (Vol. 19, Issue #6) June 2019 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 302691530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530. For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. ÂŠ 2019

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contents features

PUBLISHER John M. Krieg

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VICE PRESIDENT Kristin Leavoy

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EDITOR John Wallace

SPOTLIGHT ON

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Brenda Muchelli, RN, BSN

ART DEPARTMENT Jonathan Riley Karlee Gower Kathryn Keur

ACCOUNT EXECUTIVES Jayme McKelvey Megan Cabot

DIGITAL SERVICES

win a free pair of Calzuro shoes!

Rachel’s Very Beginner Cream Biscuits

OR TODAY CONTEST

RECIPE OF THE MONTH

Cindy Galindo Kennedy Krieg

CIRCULATION Lisa Cover Melissa Brand

WEBINARS Linda Hasluem

INDUSTRY INSIGHTS 11 News & Notes 24 C CI: The 3 P’s of Portfolio Development: Practical, Portable, Professional 26 IAHCSMM: CS/SP FAQs: Surveys, Jewelry, Box Contaminants and More 28 ASCA: This Summer, Invest in Yourself and Your ASC 31 Webinar Re-cap: Webinar Addresses OR Smoke

ACCOUNTING Diane Costea

IN THE OR 33 Market Analysis: Infection Control 34 Product Focus: Infection Control 40 CE Article: C. Difficile

OUT OF THE OR 54 Spotlight On 56 Fitness 59 Health 61 EQ Factor 62 Nutrition 64 Recipe 66 Pinboard 68 AORN Scrapbook

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INDUSTRY INSIGHTS

AAAHC Celebrates 40 Years The Accreditation Association for Ambulatory Health Care (AAAHC) is celebrating its 40th anniversary as a leader in ambulatory health care accreditation. Over the past four decades, AAAHC has driven quality improvement in ambulatory patient care through a quality-focused, peer-based and educational accreditation process. With an exclusive focus on ambulatory health care, AAAHC has developed rigorous, comprehensive, nationally recognized standards to guide health care facility compliance with best practices and patient-safety guidelines. All AAAHC surveyors have experience in the ambulatory setting, ensuring an expert-guided survey experience from start to finish. And, throughout the three-year accreditation cycle, AAAHC provides live and webinar-based education programs to help participating facilities understand and maintain compliance. “More than 6,100 facilities have earned the AAAHC Certificate of Accreditation over the past 40 years, an achievement that speaks to our organization’s commitment to providing safe, high-quality health care services to patients,” said Arnaldo Valedon, MD, anesthesiologist and AAAHC board chair. “As we embark on the next decade, our focus remains on our mission to increase value to health care organizations and the patients they care for, while striving to foster an accreditation mindset – before, during and in between accreditation surveys.” In 2019, AAAHC plans to take bold steps toward refining and strengthening the delivery of its mission and lead the transformation of ambulatory health care, including: • Engaging with clients more frequently throughout the accreditation cycle with tools, resources and education that bring meaningful value when they need it. • Focusing facilities’ efforts on robust, evidence-based standards that are relevant and specific to their setting and practice. • Holding accredited clients accountable for implementing plans of correction and conducting annual gap assessments. • Strengthening the quality and consistency of surveyors and the education that they deliver. • Delivering interactive and engaging education that is conveniently accessible to providers. • Expanding its portfolio to include certifications programs for organizations seeking to be recognized for excellence in the specialty health care services they provide. • For more information, visit www.aaahc.org.

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news & notes

Healthmark Offers Double End Acetabular Brushes Healthmark Industries is pleased to announce the addition of the Double End Acetabular Reamer Brush to its ProSys Instrument Care product line. This brush is manufactured for cleaning acetabular reamers, the Double End Acetabular Reamer Brush is designed with a latex-free thermoplastic handle and bristles. Equipped with durable rigid brush fibers that assist with debris removal, the reusable double ended brush allows health care workers to clean inside acetabular reamers and individual cutting holes. • For more information, visit www.hmark.com.

JUNE 2019 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

Brainlab Acquires Robotics Platform Company Brainlab has announced the acquisition of Medineering, a developer of application-specific robotic technologies. With this move, Brainlab is driving the democratization of digital surgery with scalable solutions that expand clinical frontiers. This strategic move increases the depth of the Brainlab portfolio in cranial surgery and strengthens its offering in spinal surgery by contributing a powerful digital step in clinical workflows. Brainlab currently markets the Medineering arm under the name Cirq. Inspired by the form of the human arm, Cirq is an intuitive assistant during surgical procedures. After quick setup, highly adaptable Cirq can be aligned in seven degrees of freedom for maximum positioning flexibility. Once Cirq is locked firmly in place, surgeons are free to focus on subsequent surgical steps with both hands. Navigation integration leverages established workflows, set-up and instrumentation and extends utilization. The combination of a base arm and attachable “hand” modules makes Cirq scalable and future-proof. The acquisition adds another platform to the open hardware architecture of the Brainlab digital ecosystem for surgery, enabling other medical technology companies to design their own solutions and applications across many subspecialties. Unlike other closed monolithic industry offerings, this acquisition is expected to offer an open platform for a broad range of clinical opportunities. “Becoming part of Brainlab means scalability for our technology and improved market access,” Medineering CEO Stephan Nowatschin said. “Combining our open platform with the software ecosystem from Brainlab will enable more efficient development of very competitive clinical solutions.” “Medineering introduced a fresh new approach to surgical robotics when we entered into our partnership less than three years ago,” Brainlab CEO Stefan Vilsmeier said. “Today, we are shifting gears and accelerating development with additional resources to address a broader clinical market.” •

12 | OR TODAY | JUNE 2019

Barrett Hospital & HealthCare Invests in UV Technology Barrett Hospital & HealthCare has invested in two Clorox Healthcare Optimum-UV Enlight Systems. The ultraviolet technology helps protect the hospital environment by killing pathogens that can cause healthcareassociated infections (HAIs). Barrett Hospital & HealthCare is a nonprofit critical access hospital and trauma receiving center serving the rural southwestern region of Montana. While the hospital provides a range of services and care, space is dedicated to cancer care, wound care, infusions and scheduled diagnostics. These patients have high sensitivities toward bacteria and viruses. “Because our hospital serves such a large geographic area, our patients rely heavily on our facility to provide high-quality care and we need to be prepared for anything,” said Carol Kennedy, RN, MSN, chief clinical officer at Barrett Hospital & HealthCare. “A lot of hard work and effort goes into how we clean throughout our hospital. We’re passionate about patient safety and very excited about the system’s ability to help keep infection rates low. Incorporating the Clorox Healthcare Optimum-UV Enlight System into our existing cleaning and disinfecting protocols worked so well for us that we’ve invested in two.” “The Clorox Healthcare Optimum-UV Enlight System works by emitting UV-C light and killing microorganisms by inactivating their DNA, rendering them harmless and unable to multiply or spread. The UV-C rays disinfect areas within an 8-foot radius in just five minutes and can extend a full 360 degrees, offering health care facilities an additional layer of protection without adding time to infection prevention protocols,” according to a press release. Barrett Hospital & HealthCare employs two units for utilization in all areas of its north campus and main facility including in-patient, isolation and discharge rooms, the walk-in clinic and in the operating rooms after each surgical case. “The system is easy to use and effective, which assists us to serve our patients well,” added Kennedy. “We know that this investment will help us advance our care delivery and improve patient outcomes.” •

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DJO Launches Adaptable Surgical Arm at AAOS DJO, a provider of medical technologies designed to get and keep people moving, introduced the Adaptable Surgical Arm at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). Adaptable is the first fully sterile, surgeon-controlled leg and retractor holder designed for a safe direct anterior approach (DAA) total hip arthroplasty (THA). The fully mechanical, carbon fiber surgical arm works seamlessly with any standard operating table and has the ability to reduce the number of assistants in the operating room. Adaptable is easy to set up, transport and store. The Adaptable Surgical Arm is a fraction of the cost and weight of traditional specialty tables. It can be easily transported between hospitals and weighs approximately 10 pounds. This two-in-one solution can be used for retractor placement or leg positioning for femoral exposure, range of movement and leg length assessment. •

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INDUSTRY INSIGHTS

news & notes

TroClose1200 Access-Closure System Used in 2,000+ Surgeries Gordian Surgical announced that it has surpassed 2,000 surgeries globally with its FDAcleared and CE-marked TroClose1200 accessand-closure system for laparoscopic surgery. Until recently, surgeons had to either manually insert sutures in a time-consuming and sometimes difficult process at the conclusion of a lap surgical procedure, or close the lap portsite opening with an additional device. Improper lap port closure may result in an incidence of hernia up to 6 percent, where the intestine protrudes from a weakened abdominal muscle, necessitating additional surgery. Now, using the TroClose1200’s design, sutures are inserted into the tissue at the beginning of the procedure and anchored to remain in place throughout the operation, allowing port site incisions to be closed easily and quickly as designed upon removal of the TroClose1200 system. “TroClose is a simple, effective device to close laparoscopic incisions. No longer do I have to point a sharp instrument toward the intestine or major blood vessels in the abdomen to close a 10-millimeter port. Besides saving time in the OR, TroClose will reduce inadvertent injury,” said Barry Salky, MD, Professor Emeritus of Surgery and Founder of the Division of Laparoscopic Surgery at Mount Sinai Hospital, New York, New York. “This is a very exciting time for Gordian Surgical,” said Zvi Peer, CEO of Gordian Surgical. “We are an advanced-stage medical device company with not only outstanding clinical data from more than 2,000 surgeries, but also FDA/CE regulatory certifications and significant investments from B. Braun and other investment groups. We are ramping sales with a patented product that meets a critically important clinical need: improved safety in lap surgery.” •

14 | OR TODAY | JUNE 2019

Fujifilm Introduces Interlock Trocar Fujifilm New Development U.S.A. Inc., a provider of minimally invasive surgical solutions, introduced its new Fujifilm InterLock Trocar, a novel tandem motion visualization device that allows a surgeon to control both a laparoscope and a hand instrument at the same time and with one hand. “We’re excited to demonstrate the Fujifilm InterLock Trocar which was designed to make performing surgeries easier and more efficient for surgeons and less invasive for patients,” says Stephen Mariano, vice president and general manager, Fujifilm New Development U.S.A. Inc. “The technology represents a true paradigm shift in minimally invasive surgery. With just one small incision surgeons now have the ability to manipulate simultaneously both a laparoscope and a hand instrument with one hand. Busy ambulatory surgical centers and hospital ORs will appreciate the fact that with InterLock Trocar no additional clinician is required to control visualization while a surgeon is operating.” Fujifilm’s InterLock Trocar is uniquely designed to provide surgical access through a single incision for both a 5mm hand instrument and the Fujifilm Ultra-Slim “Chip on the Tip” HD Video Laparoscope. The technology allows the surgeon full control of the scope throughout the procedure by directly controlling the hand instrument. Tandem motion of the hand instrument and the Fujifilm scope is achieved through a unique coupling mechanism within the InterLock Trocar. Additional features include an integrated lens cleaning function, which allows the lens to be cleaned and restores brilliant image quality without removing the scope from the trocar – saving time and reducing the need for repositioning. The InterLock Trocar was also designed to adjust and maintain the image horizon regardless of hand instrument positioning and orientation. Finally, Fujifilm’s advanced Ultra-Slim video laparoscope system delivers exceptional image resolution, excellent color fidelity, and sharp display quality – all while featuring a comfortable, ergonomic design. The device is compatible with most common 5mm hand instruments on the market. Fujifilm’s InterLock Trocar has received 510k clearance from the FDA, and will be commercially available in the United States later this year. •

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news & notes

Healthmark Industries Celebrates 50th Anniversary Healthmark Industries, a family-owned health care supplier located in Fraser, Michigan, is celebrating its 50th year in business in this year. Ralph A. Basile and his wife, Suzanne, established Healthmark in 1969 in Grosse Pointe, Michigan. After a successful career in medical sales, Ralph decided to start his own company. In the early days, Healthmark was operated out of the family home, for their first-generation products. After a few years of success and growing business, Healthmark moved to its first “real” office on the corner of Mack Avenue and Harvard Road in Grosse Pointe Park. Continued success led to the need for a larger facility, and in 1979 Healthmark moved to a building on 9 Mile between Mack and Jefferson in St. Clair Shores. Right from the start, Healthmark operated as a family business. Sons Ralph, Mark and Steve were among Healthmark’s first “employees,” stamping literature with the company information on a pay-for-piece basis. Ralph jokes that he still has paper cuts from those days. Later on, each of the sons, at different times and with different prior experiences, joined the family business and helped grow it. Healthmark’s founder and patriarch, Ralph A. Basile, passed away in 2001 after a battle with cancer. Through the efforts of his wife, three sons, grandchildren and many loyal employees, the company has continued to grow. Healthmark Industries provides innovative and costeffective products for health care customers to meet their sterilization, decontamination, storage, distribution and security needs. Today, Healthmark continues as a family business to develop innovative solutions to aid health care facilities worldwide. Currently the company is run by Ralph and Suzanne’s three sons, Ralph, Mark, and Steve, with Suzanne still very much involved. Grandson Daniel Basile and wife, Theresa, recently joined the company, as did granddaughter Ashlynn Basile, continuing Healthmark as a third-generation family business. Suzanne Basile reflects fondly on the past and is excited

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to see what the future brings for Healthmark. “I thank my sons and our wonderful employees who have carried on the legacy of our great company so beautifully, and now it is our grandchildren’s turn to carry Healthmark forward into the future, meeting the needs of our customers as we have always strived to do,” she said. Healthmark looks forward to an exciting future with its growing staff and continued expansion of a variety of products and services. After 50 years of service to the health care industry, Healthmark continues to adapt to the business needs of its customers. Healthmark currently employs more than 200 people and recently moved into a 100,000-square-foot headquarters in Fraser, Michigan. • For more information, visit www.hmark.com.

JUNE 2019 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

New XL Transport Container Protects Instruments InstruSafe by Summit Medical, an Innovia Medical Company, recently introduced the new InstruSafe XL Transport Container. It is designed to accommodate da Vinci SP, Xi Scopes, EndoWrist and other long laparoscopic surgical instruments. The XL Transport Container extends Summit Medical’s manufacturing of InstruSafe Instrument Protection Trays that are custom designed to protect virtually any surgical instrumentation from the sterile processing to the operating room. InstruSafe’s Instrument Protection Trays and its new XL Transport Container were demonstrated during the AORN Global Surgical Conference & Expo in Nashville, Tennessee and at the IAHCSMM Annual Conference in Anaheim, California. “Transporting surgical instruments safely and effectively is difficult. As health care facilities continue to invest in larger, delicate and costly robotic instruments, we recognized the need to better protect them from the OR to sterile processing,” said Kevin McIntosh, president of Summit Medical. “With our new XL Transport Container, InstruSafe

expands its commitment to raising quality standards for how delicate, expensive surgical instrumentation is organized, sterilized, transported and stored.” With InstruSafe’s XL Transport Container, the cleaning process for da Vinci and other laparoscopic instruments can now start in the OR for more efficient and safe reprocessing and transport. The large, horizontal container features an inner gasket, lid and four silicone latches to reduce spills, and a drain to accommodate soiled liquid removal. InstruSafe’s investment in manufacturing the XL Transport Container and its custom InstruSafe Instrument Protection Trays for health care facilities has generated exponential growth, requiring a second distribution facility that opened in 2019. The company’s growth was fueled by the rise of minimally invasive surgery, increasingly complex surgical instruments and an intensified focus on infection control. • For more information, visit www.InstruSafe.com.

Hip Replacement Surgery Performed with Alteon Cup, XLE Liner Exactech, a developer and producer of bone and joint restoration products for extremities, hip and knee, has announced the first successful surgery using its recently cleared Alteon Cup and XLE Liner. Orthopaedic surgeon and member of the Alteon Cup design team, William Hefley, M.D., of Bowen-Hefley Orthopedics in Little Rock, Arkansas, performed the first case. “Two years of development work came together in the OR today. I’m very pleased with the final design of the Alteon Cup and XLE liner,” Hefley reported. “The cup has a great

16 | OR TODAY | JUNE 2019

scratch-fit and the liner placement is seamless. I look forward to seeing the long-term benefits these advancements could bring my patients.” The Alteon Cup and XLE Liner are the newest additions to Exactech’s Alteon Platform Hip Replacement System. The cup will provide multiple implant configurations and bearing options, which can be used for various surgical applications. •

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INDUSTRY INSIGHTS

news & notes

Colorado Nurses Look Forward to Smoke-Free Operating Rooms Colorado Governor Jared Polis has signed into law new legislation that will require licensed hospitals and ambulatory surgery centers to adopt and implement policies to prevent human exposure to surgical smoke. Surgical smoke results from thermal destruction of human tissue by heat producing devices such as lasers and electrocautery knives commonly used during surgery. The new law covers all planned surgical procedures likely to generate surgical smoke and becomes effective May 1, 2021. Colorado follows Rhode Island in this legislative commitment to the protection and safety of perioperative nurses and their colleagues on the surgical team. The Association of periOperative Registered Nurses (AORN) spearheaded the law’s passage with the support of the Colorado Nurses Association and the Colorado Hospital Association. “After hearing from our nurses about the need for uniform evacuation procedures to eliminate surgical smoke in

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their operating rooms, lawmakers agreed to take this action to ensure smoke-free operating rooms for the state’s surgical teams,” said Amy Hader, AORN director of government affairs. “Colorado’s early lead on this important issue will help the state attract and retain top surgical nursing talent for years to come.” According to the Occupational Health and Safety Administration (OSHA), each year an estimated 500,000 workers, including surgeons, nurses, anesthesia professionals, and surgical technologists, are exposed to laser or electrosurgical smoke. This smoke plume can contain toxic gases and vapors such as benzene, hydrogen cyanide, and formaldehyde, bioaerosols, dead and live cellular material (including blood fragments), and viruses. Prolonged exposure – of the kind experienced by perioperative registered nurses – can lead to serious and life-threatening respiratory diseases. •

JUNE 2019 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

Ecomed Solutions Introduces HEMAsavR Ecomed Solutions has created and unveiled HEMAsavR, a new device and option for blood capture and transfer that will help medical professionals reduce costly and complex allogeneic blood transfusions. In any surgery, there is the potential for blood loss, but it is difficult to predict who will bleed and harder still to efficiently and economically salvage blood. HEMAsavR is a unique sterile collection and transfer device that does not require specialized resources for collection. This enables medical professionals and hospitals interested in blood management to economically collect more viable sterile and anticoagulated blood for evaluation for cell salvage processing and return to the patient. “Allogeneic transfusions are among the costliest contributors to health care expenditures,” said David Yurek, CEO of Ecomed Solutions. “Reducing the need for allogeneic transfusions has a dramatic impact on health care costs and patient outcomes. Further, as our health care system is strained by shrinking donor pools, HEMAsavR can reduce that burden and improve care by providing a patient’s own blood back to them.” According to AABB, nearly 14 million allogeneic red cell units are transfused per year. These transfusions cost hospitals billions of dollars and can result in longer hospital stays, infection and even patient death. “There is a tremendous opportunity to collect more of the patient’s own blood, and HEMAsavR provides us with an effective way to do that,” said Gary Koenig, CEO of Comprehensive Blood Management Inc. “Allogeneic blood transfusions have long been an integral and necessary part of health care delivery throughout the world, but with HEMAsavR we can decrease the exposure to and risks of transfusion and achieve better patient outcomes while decreasing associated costs. Having HEMAsavR in the OR is a win-win proposition for the patient and hospital.” HEMAsavR is universally compatible with surgical

18 | OR TODAY | JUNE 2019

suction and ATS systems, making it easy to integrate into current protocols. The device is especially beneficial to hospitals that perform cardiac, vascular, orthopedic, organ transplant, trauma, OB/GYN, thoracic, general, neurosurgery and urology procedures. It also offers a critical care solution for treating patients who refuse transfusions for religious or other reasons. •

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

Company Showcase Medline

ReadyPrep CHG® 2% Pre-Saturated Cloth for Preoperative Skin Preparation SURGICAL SITE INFECTIONS: MULTIPLE PATHOGENS AND ANTIBIOTIC RESISTANCE Surgical site infections (SSIs) increase a patient’s risk of other morbidities and mortality, while increasing healthcare costs significantly.1 Asymptomatic patients who are already colonized with pathogenic bacteria, such as Staphylococcus aureus, have a significantly higher risk of developing an SSI.2 A variety of organisms can colonize a surgical incision and cause an infection, with strains that demonstrate resistance to antibiotics being particularly problematic. The most common microbial cause of SSIs in community hospitals is methicillin-resistant Staphylococcus aureus3, and one study found that 60% of infected surgical wounds contained microorganisms that demonstrated antibiotic resistant patterns.4 One technique to reduce the likelihood of an SSI, as part of an overarching SSI prevention strategy, is to cleanse the incision site prior to surgery in order to reduce the microbial burden on the skin. Given the wide array of species that can cause an infection, coupled with the prevalence of antibiotic resistant pathogens causing SSIs, an antiseptic with broad spectrum activity capable of killing drug resistant organisms has the characteristics to be an especially effective preoperative skin preparation product. Medline Industries, Inc. now offers ReadyPrep CHG® Cloth, a pre-packaged, preoperative patient skin preparation solution that demonstrates these characteristics. Each package contains two preoperative skin preparation cloths, with each cloth pre-saturated with a 2% chlorhexidine gluconate (CHG) solution that is equivalent to 500 mg CHG.

BROAD SPECTRUM ANTIMICROBIAL ACTIVITY The efficacy of ReadyPrep CHG® Cloth to kill multiple species of microorganisms was tested in a rigorous, in vitro,

time-kill study.5 The challenge microorganisms in this study included 192 isolates from 12 different organisms: Burkholderia cepacia, Candida albicans, Enterococcus faecalis, Enterococcus faecium, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Serratia marcescens, Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, and Streptococcus pyogenes. Additionally, there were multiple isolates from each organism that demonstrated resistance to antibiotics. Study results indicated the solution in ReadyPrep CHG® Cloth was efficacious in killing all isolates of all organisms, demonstrating effectiveness similar to a 2% CHG solution that served as a control in this study.

CLINICAL DATA In two pivotal clinical trials6,7, ReadyPrep CHG® Clotha met the primary endpoint for reduction of skin microorganisms in humans at ten minutes after product application. Moreover, the reductions in skin microorganisms were equal to, or significantly greater than, those caused by the active control condition, which was a commercially available liquid CHG product. Finally, skin microorganism counts remained suppressed relative to pre-treatment levels for six hours after product application. ReadyPrep CHG® Cloth was well tolerated by subjects. In all clinical studies using ReadyPrep CHG® Cloth, there were zero instances of serious adverse events; the most common side effect was temporary, mild-to-moderate skin irritation at the application site, which is consistent with the known effects of 2% CHG on the skin. Taken together, the human clinical data demonstrate ReadyPrep CHG® Cloth’s ability to reduce skin microorganisms, while the in vitro data suggest the product is efficacious against an array of microorganisms, including strains that demonstrate resistance to antibiotics.

The formulation tested in this study and all other studies described herein contained two inactive ingredients not present in the final commercial formulation. An in vitro time-kill bridging study determined that the commercial formulation and the formulation used in the pivotal efficacy studies were equally effective.8 a

22 | OR TODAY | JUNE 2019

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SPECIAL ADVERTISING SECTION

company showcase Medline

NO EVIDENCE OF INDUCING RESISTANCE TO CHG An additional in vitro study9 was carried out to assess the potential for the ReadyPrep CHG® Cloth solution to induce microorganisms to become resistant to CHG. Fortytwo isolates from eight different organisms were tested in the study. In a first phase, organisms were exposed to the ReadyPrep CHG® Cloth solution, which killed the vast majority of colony forming units (CFUs). In the second phase, the few surviving CFUs were extracted, bred, and then re-exposed to the ReadyPrep CHG® Cloth solution. In all 42 isolates from the eight different organisms, the same dosage of ReadyPrep CHG® Cloth solution applied in the first phase was needed in the second phase to kill the microorganisms. The absence of an increase in dosage needed to achieve the same effect indicates no evidence in this study of ReadyPrep CHG® Cloth inducing microorganisms to develop resistance to CHG.

ReadyPrep CHG® CLOTH: CONVENIENT AND EFFICACIOUS PREOPERATIVE SKIN PREPARATION In two pivotal trials6,7, Medline’s ReadyPrep CHG® Cloth met the primary endpoint for efficacy in reducing skin microorganisms at ten minutes post-treatment, and the number of microorganisms remained suppressed six hours after initial treatment. Data from in vitro studies demonstrates that the ReadyPrep CHG® Cloth solution is effective against a wide array of pathogens, including strains demonstrating antibiotic resistance. By significantly reducing skin microorganisms, ReadyPrep CHG® Cloth represents a WWW.ORTODAY.COM

critical tool in overall preoperative patient preparation in an effort to prevent surgical site infections. For more information, visit www.medline.com/pages/chg/

REFERENCES 1. Leaper D, Ousey K. Evidence update on prevention of surgical site infection. Curr Opin Infect Dis. 2015;28(2):158-163. 2. Skramm I, Moen AE. Surgical site infections in orthopaedic surgery demonstrate clones similar to those in orthopaedic Staphylococcus aueus nasal carriers. J Bone Joint Surg. 2014;96:882-888. 3. Anderson DJ, Sexton DJ, Kanafani ZA, Auten G, Kaye KS. Severe surgical site infection in community hospitals: Epidemiology, key procedures, and the changing prevalence of Methicillin-Resistant Staphylococcus aureus. Infect Control Hosp Epidemiol. 2007; 28(9): 1047-1053. 4. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014; 370: 1198–208. 5. Data on file. Medline Industries Study #R14-013. 6. Data on file. Medline Industries Study #R13-053. 7. Data on file. Medline Industries Study #R15-029. 8. Data on file. Medline Industries Study #R17-004. 9. Data on file. Medline Industries Study #R14-012.

JUNE 2019 | OR TODAY |

INDUSTRY INSIGHTS CCI

The 3 P’s of Portfolio Development: Practical, Portable, Professional By Juliana Mower, MSN, RN, CNS, CNS-CP, CNOR ven with the welldocumented nursing shortage, a coveted perioperative position may be difficult to procure. What can you use to set yourself apart from the dozens of other candidates for a job? A wellcrafted Curriculum Vitae (CV) or resume only lists your educational background, employment history and professional accomplishments. What if you could show a prospective employer the quality of your work? You can – through a professional portfolio.

When used to document competencies, a portfolio becomes more than a repository for storing forms such as nursing licenses, certifications and letters of reference. A portfolio can be used to reflect your professional identity by including feedback from peers and colleagues, patient satisfaction surveys or thank-you notes, participation on committees or quality improvement projects, and contributions toward professional organizations (Casey & Egan, 2010). Consider adding an exemplar, an example of an extraordinary accomplishment, with associated evidence, that establishes

24 | OR TODAY | JUNE 2019

your commitment to your profession and/or organization. A portfolio may be used for more than interviewing purposes. It can serve as a valuable tool for performance evaluations through identification of personal strengths as well as areas for improvement. By including a self-assessment step, a personal development plan can be created (Williams & Jordan, 2007). Self-assessment is part of reflective learning. Nurses are familiar with reflective learning as this is the basis for debriefings: identifying what went well, what didn’t and designing a plan for improvements for next time (Casey & Dominic, 2010). Consider adding this element to your portfolio. It is a great way to track professional growth and demonstrates a commitment to life-long learning. Describing how learning was applied in practice provides much stronger evidence for linking knowledge to application of skills rather than an in-service roster which only identifies physical presence at an event. Portfolio development is best approached proactively rather than retrospectively. Trying to access or reproduce evidence, even from the past month, can be difficult. It’s better to develop a portfolio over time, col-

lecting the necessary documentation at the time of the event and then correlating these achievements in the CV or resume (Shirey, 2009). Portfolios are beginning to be used for more than employment opportunities. The Competency and Credentialing Institute (CCI) recently launched a portfolio method of certification for advanced practice Clinical Nurse Specialists (CNSs), the CNS-CP Professional Portfolio (CCI, 2019). This portfolio captures the essence of the practicing CNS through validation of contributions toward improving patient outcomes. In addition to documentation of meeting standards for advanced practice in the perioperative role, the portfolio contains a reflective component and a self-awareness exercise which is used to build the requirements for the next recertification cycle. The portfolio is then reviewed by three peers who hold the CNSCP credential. Their independent review of the portfolio determines if the submission meets the requirements for certification, while at the same time providing valuable feedback to the applicant on the strength of their submission. Peer review encourages self-awareness for both the applicant and the reviewers through WWW.ORTODAY.COM

TREAT YOUR FEET

the dissemination of best practices. Receiving feedback from reviewers can be considered a value-add for the CNS-CP Professional Portfolio: perioperative CNSs frequently do not have a peer in their facility from whom to obtain constructive comments related to their practice. Look for other uses of portfolios in the future, including as requirements for state re-licensure, clinical ladders and for specialty nursing certification and re-certification. As a tangible, continually evolving collection of activities that demonstrates continued competency, the portfolio might be the best way to accurately reflect the quality of care you provide for your patients every day.Â

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References Casey, D.C., & Egan, D. (2010). The use of professional portfolios and profiles for career enhancement. British Journal of Community Nursing, 15(11), 547-548; 550552. Competency and Credentialing Institute (CCI). (2019). About CNS-CP certification. Retrieved from https:// www.cc-institute.org/cns-cp/certification. Shirey, M.R. (2009). The nursing professional portfolio: Leveraging your talents. Clinical Nurse Specialist, 23(5), 241-244.

PERSONALIZE SCRUBS WITH AN ARRAY OF COLORS

Williams, M., & Jordan, K. (2007). The nursing professional portfolio: A pathway to career development. Journal for Nurses in Staff Development, 26(3), 125-131. Juliana Mower, MSN, RN, CNS, CNS-CP, CNOR, is nurse manager, education development at CCI.

WWW.ORTODAY.COM

WWW.CALZURO.COM 800.257.9472 JUNE 2019 | OR TODAY |

INDUSTRY INSIGHTS

IAHCSMM

Central Service/Sterile Processing FAQs: Surveys, Jewelry, Box Contaminants and More he International Association of Healthcare Central Service Materiel Management (IAHCSMM) routinely fields questions from members about various aspects of the Central Service/Sterile Processing (CS/SP) profession. What follows are some of the more frequently asked questions, answered by IAHCSMM Education Director Natalie Lind, CRCST, CHL, FCS.

Q: We recently had a Centers for Medicare and Medicaid Services survey and the inspector questioned our policy for testing our cleaning equipment. We showed him that we follow ANSI/ AAMI ST79, Comprehensive guide to steam sterilization and sterility assurance in health care facilities, and presented him with our documentation of checking each piece of equipment weekly. He told us the standard had changed and we needed to comply with the new standard. Can you please tell me the new standard? A: With the release of ANSI/AAMI ST79: 2017, the standard for testing equipment changed from weekly or preferably daily to testing each day of use. Q: Can I wear my wedding ring while working in the Central Service/Sterile Processing department? A: ANSI/AAMI ST79, Comprehensive guide to steam sterilization and sterility assurance in health care facilities, section 4.5.1, states that jewelry and wristwatches should not be worn in the decontamination, preparation or sterilization areas. Jewelry should not be worn because it can harbor microorganisms and also cause holes

26 | OR TODAY | JUNE 2019

in gloves or other barriers intended for protection. Wristwatches and rings, in particular, can also catch on equipment or instruments, which may injure personnel or damage the item or packaging. Q: When our Central Service/ Sterile Processing employees work for long periods of time at the sink in the decontamination area, they develop back and foot discomfort. We would like to use anti-fatigue mats at the sinks. Is it acceptable to have these mats in the decontamination area? A: Anti-fatigue mats have been shown to reduce back and foot discomfort, and they may be used in the decontamination area; however, there are a few important features to consider when selecting the right type of mat. First, it should be a gel foot pad that can withstand daily cleaning and disinfection with an Environmental Protection Agencyregistered, hospital-grade disinfectant. To help prevent trips and falls, the mat should also have tapered edges to ease the transition from the mat height to the floor. To reduce the risk of slips, the mat should have a slip-resistant bottom/underside and the top/upper part of the mat should feature an anti-skid surface.

Natalie Lind, CRCST, CHL, FCS, IAHCSMM Education Director

Q: We received an item for surgery that needs to be returned to the manufacturer after its use. We donâ&#x20AC;&#x2122;t want to lose the box the item was delivered in, so can the Central Service/Sterile Processing department store the box until the item is ready to be returned? A: According to ANSI/AAMI ST79:2017, Comprehensive guide to steam sterilization and sterility assurance in health care facility standard, Section 3.3.6.5 Breakout area/room, neither corrugated boxes nor shipping boxes are permitted in the CS/SP and surgical areas (any box taken into a CS/ SP or surgical area must also not have web edges or generate dust). Received shipping boxes can be left in a breakout room, which is near or adjacent to a surgical area or the CS/SP department. WWW.ORTODAY.COM

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INDUSTRY INSIGHTS update

This Summer, Invest in Yourself and Your ASC By William Prentice, ASCA Chief Executive Officer ummer is fast approaching, and for many of us that means making time to relax and recharge. For some, that translates into vacation travel; for others, time at home focused on the things we never find time to do the rest of the year.

If you work in an ASC – or want to one day – I encourage you to devote some part of your summer this year to your own professional development. If you are already working in an ASC, I also encourage you to look at ways you and others on staff can invest time this summer in professional development that will lead to improvements inside your facility in areas like patient satisfaction, improved safety for your patients and staff, better billing and collections and a renewed commitment to meeting and exceeding the regulatory standards that guide all you do each day. If you don’t already hold your Certified Ambulatory Infection Preventionist (CAIP) or Certified Administrator Surgery Center (CASC) credential, one of the first questions you should ask yourself is whether one or both of those credentials would help you take your skills and your career to the next level. Both credentials are administered by the Board of Ambulatory Surgery Certification (BASC), and both were developed specifically to meet the needs of health and business professionals who work in ASCs. The CAIP credential was introduced just last year. It recognizes expertise in infection prevention in the ASC setting and allows credential holders to demonstrate their commitment to remaining current on this critically important, ever-evolving aspect of ASC operations. To take the next available exam for this credential this October, you will need to apply during August. To pass the exam, you will need to demonstrate expertise in five areas: • Infection prevention program development, implementation and maintenance • Infection prevention and control education and training • Surveillance, data collection and analysis • Infection prevention strategies

28 | OR TODAY | JUNE 2019

• Instrument/equipment cleaning, disinfection and sterilization The CAIP website, www.aboutcaip.org, includes a long list of resources you can study over the summer to prepare. You don’t need to review them all, especially if you are already providing infection prevention services in your ASC, but once you determine the areas where you need to learn more, you can find a resource there to help. You can also find sample test questions on that site and everything you need to know about earning and maintaining the credential. The CASC credential has been available since 2002. It recognizes a comprehensive understanding of the unique skill set and knowledge required to serve as an ASC administrator. You don’t have to be an ASC administrator to earn the credential, you just have to know what it takes and how to apply that knowledge effectively. You need to apply in July to take the next CASC exam, which will be administered this September. Like the CAIP website does for the CAIP credential, the CASC website, www.aboutcasc.org, has everything you need to know to qualify for and maintain the CASC credential, including a list of study materials you could review this summer. CASC credential holders routinely tell us that having the credential has helped them move forward in their careers, demonstrate their proficiency to their colleagues and save time with vendors and others they work with outside their ASC by letting them know at a glance that they have the expertise they need to manage the tasks at hand. They also say that making the commitment to continuously update their skills and knowledge – part of the process of maintaining the credential – has helped them keep their patients safe and their surgery center compliant with new regulatory requirements as they are introduced. If you want to look beyond the CAIP and CASC credentials for other ways to improve the care and services you provide, ASCA has plenty of resources that can help. This year, we released a new edition of our “Finance & Accounting for ASCs” guide. This edition includes revised WWW.ORTODAY.COM

INDUSTRY INSIGHTS update

and expanded content that walks you through ways to create and use key financial statements, steps you need to take to manage your inventory cycle, how to project your annual budget and respond to variances there and much more. This fourth edition is a valuable resource for CASC candidates looking to learn more about financial management in an ASC and sells at a new, lower price. ASCA members get an additional discount. If you want to make sure your Health Insurance Portability and Accountability Act (HIPAA) policies cover everything they need to cover, download ASCA’s HIPAA Workbook. ASCA members can download their copies free. If you’re looking for practical advice from experts on everything from negotiating your managed care contracts to responding to complaints and mastering the requirements of Medicare’s quality reporting program, take a look at ASCA’s 2019 webinar series. Some of the live programs are available free, or you can subscribe to the entire series and listen to the live and recorded programs as your schedule allows.

Also, it’s not too late to enroll in ASCA’s 2019 Clinical and Operational Benchmarking Survey. You don’t have to be an ASCA member to enroll, but you do have to be enrolling as an ASC. Hospital outpatient department data is not included in this program. I can’t list everything that ASCA offers ASCs in one short column, so I will refer you to ASCA’s website, www. ascassociation.org, to see more. All the tools and opportunities you will find there are uniquely targeted to ASCs and their staff. Pick one or two to explore this summer and put others on your calendar for later this year. ASCA can’t help you book your vacation or tell you the best way to tackle that DIY project you’ve been planning, but if your future involves an ASC, we can help you invest in yourself and your career. I encourage you take advantage of all the opportunities ASCA offers you. William Prentice is the ASCA chief executive officer.

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INDUSTRY INSIGHTS

WEBINAR SERIES

webinars

Webinar Addresses OR Smoke Staff report he OR Today webinar series continues. Brenda Ulmer presented “CSI - Smoke: Is the OR the Scene of a Crime?” on March 21 to about 100 attendees and more have viewed a recording of the webinar online. Attendees were eligible for one continuing education (CE) hour by the State of California Board of Registered Nursing.

Ulmer, RN, MN, CNOR, is a perioperative nurse educator. The webinar asked, what is a Crime Scene Investigation (CSI)? Because of the popularity of television shows such as CSI, the public is shown how forensic evidence is used to solve crimes in a scientific and systematic manner. Forensic evidence is routinely used in health care. It seems, therefore, reasonable, and potentially beneficial, to apply the same scientific methods to surgical and invasive procedures to establish the health of the environment – or lack thereof – in which health care professionals practice. In spite of ongoing efforts, there are those who still question the necessity of removing and filtering surgical smoke. This session followed the scientific evidence that documents surgical smoke as a health hazard and made recommendations to assist perioperative personnel in the adoption and implementation of establishing a safe work environment for all health care professionals who practice in settings where operative and invasive procedures are performed. Attendees gave the webinar and the webinar series positive reviews via a post-webinar survey. “OR Today’s webinar series presents relevant topics that impact our operating rooms across the country,” said J. Emerick, Clinical Instructor Educator. “I really enjoyed the presentation topic and the presenters experience. We are trying to get our OR to be smoke free,” said R. Hance, RN Quality & Safety. “The webinar was very informative and reminded us all of what we need to do to continue to take care of ourselves while working in the OR. An OR nurse usually is in a job for many years and this just helps remind us all of the potential risks we take every day,” said G. Schilthuis, Clinical Director. “I am an old-school nurse when we did not use any WWW.ORTODAY.COM

“ Excellent webinar! I learned a lot of new information and am motivated to implement some changes in my OR to prevent smoke exposure.” – M. Cabral, OR RN. evacuation. Today, I hear my peers from way back when clearing their throat and coughing. This was an excellent education experience,” said T. Fuchs, Director of Surgical Services. “Excellent webinar! I learned a lot of new information and am motivated to implement some changes in my OR to prevent smoke exposure,” said M. Cabral, OR RN. “The resources provided in this webinar will assist our perioperative Best Practice Committee in establishing AORN’s Go Clear Program in our OR. Thanks to Brenda and her webinar for being the springboard,” said M. Corriveau, OR RN. “Awesome webinar! Very informative and excited to share with staff the information that was provided today! Thank you for bringing this to light to make the ORs a safer place to work,” said A. Henke, RN Team Lead CNOR. “The webinar was very informative and helpful in driving organizations into a OR smoke free facility,” said A. Dayucos, Perioperative CNS. “This presentation was presented in a manner to capture your attention. Love the CSI team theme. As an infection prevention nurse, I am approached by the OR staff who are concerned most often by the Human Papilloma Virus and possible exposure. It is very enlightening to know that there are so many other chemicals and toxins that may affect their health as well. Thank you for all of your work to protect the OR associates,” said J. Joynes, RN Infection Preventionist. For more information about the webinar series, visit ORToday.com. JUNE 2019 | OR TODAY |

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The TBJ Model 30-96-2TB SPCS work sink is specifically designed for use in GI Labs and Sterile Processing Departments for the pre-cleaning flexible endoscopes. The unit includes two elongated trough style bowls allowing for the extended linear positioning of endoscopes during the pre-cleaning process to promote cleaning efficiency. Features include: - (2) trough sinks shall be 72” long x 9” deep - The sink shall include (2) push-button automatic fill systems (one for each bowl) with level sensors and overflows

TBJ sinks are designed specifically for the pre-cleaning of surgical instruments and endoscopes. All of our sinks are custom made to order to enable you to design a system around your specific needs. A wide range of optional features and accessories enable you to tailor a design that puts the tools you for efficient, effective and ergonomic pre-cleaning right at your fingertips.

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- One sink shall be designated for dosing and flushing and one sink shall be designated for rinsing and purging - The dosing and flushing sink shall include push-button detergent dosing with two adjustable pre-sets and constant temperature monitoring - Both sinks include integral connec tions ports for flushing, rinsing and purging - The sink top shall be adjustable allowing the sink height to be adjusted from 34” to 42” high via a push-button control - The sink shall include a full-length under counter storage shelf for detergent placement

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market analysis

Infection Control Remains Dynamic Market Staff report tion and rising incidence of chronic diseases along with the technological advancements in sterilization equipment have been driving the global infection control market. On the contrary part, safety concerns regarding the reprocessed instruments might act as a restraint for the overall market,” according to Verified Market Research. MarketsandMarkets also predicts continued growth in the infection control market. “The infection control market is projected to reach $27.5 billion by 2024 from $20.0 billion in 2019, at a CAGR of 6.6 percent during the forecast period. The infection control market is largely driven by the high incidence of HAIs and SSIs; the increasing number of surgical procedures worldwide, the rapidly growing pharmaceutical, life science and medical device industry; and the growing According to Verified Market Research, need for food sterilization,” according the global infection control market was to MarketsandMarkets. The endoscope reprocessing prodvalued at $17.86 billion in 2018 and ucts segment, disinfectant sprays is projected to reach $29.58 billion by segment and the UV-ray disinfectors 2026, growing at a compound annual segment are all expected to fuel growth. growth rate (CAGR) of 6.5 percent “Based on products and services, from 2019 to 2026. the endoscope reprocessing products In the report, the market outlook segment is expected to grow at the section mainly encompasses the fundahighest CAGR during the forecast mental dynamics of the market which period. This can be attributed to the include drivers, restraints, opportunities growing importance of diagnostic and and challenges faced by the industry. therapeutic endoscopy procedures, “The growing number of surgical procedures, increasing geriatric popula- advanced technologies, reasonably nfection control is defined as the policies and procedures that are used to minimize the risk of spreading infections, particularly in hospitals and human or animal health care facilities. The main purpose of the infection control process is the reduction of the occurrence of infectious diseases. These diseases are usually caused due to the presence of bacteria or viruses and can further spread through human contact, animal to human contact, human contact with an infected surface, airborne transmission and through vectors such as water or food. Different forms of infections can occur including lung and respiratory infections, skin infections and many others.

WWW.ORTODAY.COM

stable reimbursement scenario and concerns regarding patient-to-patient cross-infection caused due to improper endoscope reprocessing,” according to MarketsandMarkets. “Disinfectant sprays – used in fogging of hospital rooms and operation theaters – are increasingly being adopted due to its ease of handling and effectiveness in serving the purpose of room and surface disinfection,” according to MarketsandMarkets. The MarketsandMarkets report also predicts that North America will be a strong growth area. “Geographically, the infection control market has been studied for North America, Europe, Asia Pacific, Latin America, and the Middle East & Africa. North America is expected to dominate the infection control market during the forecast period,” according to MarketsandMarkets. “This is driven by the growing demand for health care services (owing to an anticipated surge in the geriatric population in the coming years and the subsequent increase in the prevalence of chronic diseases) and the need for infection control to minimize the prevalence of HAIs and the cost incurred due to HAIs. Many leading players are focusing on technological innovations and marketing collaborations to strengthen their presence and sustain their shares in the North American infection control market.” JUNE 2019 | OR TODAY |

IN THE OR

product focus

CenTrak

Enterprise Location Services for Infection Control CenTrak’s Enterprise Location Services for Infection Control enables real-time tracking of medical equipment, patients and staff. The improved visibility provides a means for health care facilities to prevent the spread of infection, increase patient safety and receive immediate contamination alerts. The solution also provides a cost-effective means to automatically capture compliance and noncompliance events 24/7. CenTrak’s electronic hand hygiene monitoring system captures 100 percent of hand hygiene events, eliminating the need for labor intensive, expensive and inaccurate manual direct observation. Deployable as a standalone solution or as part of CenTrak’s Enterprise Location Services platform, compliance data can be viewed at the hospital-, department- or individual-level. •

34 | OR TODAY | JUNE 2019

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IN THE OR

product focus

HALYARD and BELINTRA Smart-Fold Sterisystem

The HALYARD and BELINTRA SMART-FOLD STERISYSTEM is a unique sterilization packaging, transport and storage solution, designed to reduce the risk of tears, cuts and holes in wrapped instrument trays. The system safeguards the sterility of instruments during handling, transport and storage after sterilization until use in the OR. Its stainless steel instrument and transport wire baskets and shelves enhance organization allowing for simpler, faster storage and access to the right instruments at the right time. Additionally, they are FDA approved, have a Medical Class CE certification, and reduce touchpoints to two, exceeding the AAMI standard 79 guideline that designates three. â&#x20AC;˘

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JUNE 2019 | OR TODAY |

IN THE OR

product focus

Skin and Nasal Antiseptic Providers can take control of preoperative nasal decolonization with 3M Skin and Nasal Antiseptic (Povidone-Iodine Solution 5% w/w [0.5% available iodine] USP) Patient Preoperative Skin Preparation. This simple, one-time application reduces nasal bacteria, including S.aureus, by 99.5% in just one hour and maintains this reduction for at least 12 hours.1 • 1. 3M Study-05-011100.

ECOLAB

OxyCide Daily Disinfectant Cleaner OxyCide Daily Disinfectant Cleaner is an EPA-registered, one-step daily disinfectant cleaner and sporicide. It is proven effective in killing a broad spectrum of harmful bacteria and viruses, including C. difficile spores in three minutes and 33 other multidrug resistant organisms and viruses in five minutes or less. Designed for daily cleaning, discharges and isolation on hard nonporous inanimate surfaces, OxyCide enables product standardization and simplification, and reduces complexity of training on multiple products. Its non-bleach formula also delivers favorable material compatibility that helps minimize surface damage and dries without leaving any visible residue. •

36 | OR TODAY | JUNE 2019

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IN THE OR

product focus

Healthmark Industries TOSI

TOSI is the first device to provide a consistent, repeatable, and reliable method for evaluating the cleaning effectiveness of the automated instrument washer. The blood soil is manufactured to exacting specifications each and every time. • For more information, visit hmark.com.

TBJ

“Smart” Sinks TBJ Inc. manufactures a complete line of state-of-the-art pre-cleaning sinks designed specifically for the pre-cleaning of surgical instruments, utensils, flexible endoscopes and other miscellaneous items. TBJ sinks can be equipped with a wide variety of unique new features that enable technicians to pre-clean instrumentation more effectively and more efficiently while providing a more ergonomic workstation. Features like the HydroForce pre-cleaning system, integrated lumened instrument flushing, integrated dual-purpose ultrasonic sink, heated sinks, detergent dosing, push-button work surface height adjustment and automatic sink bowl filling are a few of the optional features. In addition, all sinks are made to order and customized around the customer’s specific needs. • For more information, visit www.tbjinc.com.

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JUNE 2019 | OR TODAY |

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IN THE OR

continuing education

C. Difficile Threatens Hospitalized Patients By Barbara Barzoloski-O’Connor, MSN, RN, CIC

n 2000, a new, more virulent epidemic strain of Clostridium difficile emerged and caused us to rethink and revamp our preventive strategies.1 This newly emerged strain of C. difficile (designated BI/ NAP1/027) is distinct from the predominant strain that circulated in hospitals in the 1980s and 1990s. It produces 16 times more toxin A and 23 times more toxin B than the earlier strain. BI/NAP1/027 also carries a gene for an additional virulence factor — a third binary toxin like a toxin in Clostridium perfringens.2 This strain of C. difficile causes disease that is more severe, more refractory to therapy, and subject to higher rates of relapse.

As the rates of BI/NAP1/027 increase in healthcare facilities throughout the United States, we are faced with the difficult challenge of keeping patients from becoming infected with these potentially severe — and sometimes fatal — bacteria. Armed with knowledge about C. difficile’s transmission and adequate infection-control measures, we can meet the challenge of helping to fight this difficult pathogen.

40 | OR TODAY | JUNE 2019

C. difficile, a gram-positive, anaerobic, spore-forming bacteria, is the major cause of nosocomial diarrhea. The organism is infectious and is transmitted via the fecal-oral route. It colonizes in the intestinal tract of humans after normal intestinal flora has been disrupted by antibiotic therapy. Depending on host factors, the outcome of colonization can range from asymptomatic carriage to severe diarrhea, pseudomembranous colitis, toxic megacolon, leukemoid reactions, severe hypoalbuminemia, intestinal perforation, requirement for colectomy, shock, and death from secondary sepsis.3 The number of cases of nosocomial C. difficile, and the proportion of cases with severe and fatal complications, have been increasing. Each year in the United States, nearly 10% of patients hospitalized for more than two weeks become infected with the pathogen at a cost estimated to exceed $4.8 billion.1,4 C. difficile infections can lengthen a patient’s hospital stay by 2.8 to 5.5 days, with average extra costs reaching as high as $3,006 to $15,937 per episode.5,6 In addition, patients with the BI/NAP1/027 strain of C. difficile have significantly higher mortality rates.7 It has also been estimated to result in death within a month of diagnosis for nearly 10% of patients older than age 65.4

Relias LLC guarantees this educational program free from bias. See Page 46 to learn how to earn CE credit for this module.

Goal and objectives The goal of this continuing education program is to inform healthcare professionals about Clostridium difficile infections in hospitals and long-term care facilities and to offer strategies for reducing the spread of this pathogen. After studying the information presented here, you will be able to: • Explain three reasons why it is difficult to control transmission of C. difficile in hospitals and long-term care facilities • Explain at least four ways the patient-to-patient spread of C. difficile can be prevented • Discuss the two major risk factors for infections with C. difficile

Hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections have been decreasing in the U.S. since 2007, while C. difficile infections (CDI) have been increasing.8 For example, from 2000 to 2005, the rate of hospitalization because of CDI WWW.ORTODAY.COM

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increased about 23% per year, and in a study conducted at 28 community hospitals from January 2008 to December 2009, hospital-acquired CDI occurred 25% more often than MRSA infections.8 C. difficile has also moved out of hospitals into the community, and infections are being diagnosed in younger and healthier people. Community-associated disease now accounts for 20% to 27% of CDI cases.8 Of these communityassociated cases, about 82% had a history of exposure to an outpatient setting such as a physician’s office or a dentist’s office within the 12 weeks leading up to the onset of symptoms and diagnosis with C. difficile.4 Nursing homes are the site of more than 100,000 cases of CDI each year.4

Who’s at Risk? Asymptomatic colonization by C. difficile can occur. But more often, exposure will allow the pathogen to establish itself in the colon when the normal flora is disrupted and resistance is impaired. Disruption of normal intestinal flora is usually caused by exposure to antibiotics.4 Even an exposure to a single dose of antibiotic, given for preoperative prophylaxis, has been linked to C. difficile infection.8 Almost all antibiotics now in use have been associated with CDI. This includes metronidazole (Flagyl) and vancomycin (Vancocin), the primary drugs used to treat CDI. The antibiotics most frequently associated with CDI, however, are cephalosporins, ampicillin (Principen) and clindamycin (Cleocin).5 Despite the known association between antibiotics and the development of C. difficile infection, an estimated 30% to 50% of antibiotics prescribed in hospitals are unnecessary or incorrect. More than 50% of antibiotics prescribed in outpatient settings are also unnecessary or inappropriate.4 An increased focus on antimicrobial stewardship and apWWW.ORTODAY.COM

propriate use of antibiotics has been demonstrated to have an impact on C. difficile infections. In one study, a 30% decrease in the use of antibiotics led to a reduction in C. difficile infections by 25%. Improved antibiotic use in England has reduced C. difficile infections by more than 50% over the years.4 Both the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research Quality have developed several tools and resources to facilitate the optimal use of antibiotics. The use of fluoroquinolones has been strongly correlated with the emergence of the BI/NAP1/027 strain. Data from a meta-analysis show that third-generation cephalosporins are the strongest risk factor, with fluoroquinolones being most strongly related to the BI/NAP1/027 strain.7 In addition, medication to reduce gastric acid production (H-2 blockers and proton pump inhibitors) has been linked to increased risk of CDI. Stomach acidity provides some protection against C. difficile bacteria when the organism is ingested.5 Nearly all CDIs occur because of fecal-oral transmission by human vectors or by contact with a contaminated environment. The contamination occurs when patients with CDI diarrhea or asymptomatic carriers of C. difficile shed the bacteria into their surroundings.8 Although the vegetative form generally dies within 24 hours after being shed, C. difficile bacteria can change to a dormant form called a spore. In this form, C. difficile is highly resistant to cleaning and disinfection measures and can survive for months on environmental surfaces.8 One study found spore contamination in 49% of rooms occupied by patients with diarrhea and 29% of rooms occupied by infected patients without diarrhea.8 Patients have a high risk of infection or colonization when they are admitted to C. difficile-contaminated rooms and cared for by staff with C. difficile

contaminated hands.8 In other studies, C. difficile spores have been recovered from bathtubs, bedpans, bedside rails, bedside tables, call buttons, door handles, equipment used to obtain vital signs or perform physical assessments, faucets, handrails, IV pumps, light switches, sinks, telephones, toilets, walkers and wheelchairs. Spores have also been recovered from clothing and stethoscopes of healthcare workers caring for infected patients.8 Risk factors for CDI include:5,6,8 Exposure to antimicrobials Age older than 65 Severe underlying illnesses Duration of hospitalization GI surgery and procedures Feeding tubes, stool softeners, GI stimulants, antiperistaltic drugs and enemas Antacids and proton pump inhibitors (acid suppressants used to treat peptic ulcers and esophageal reflux), such as lansoprazole (Prevacid), esomeprazole magnesium (Nexium) and omeprazole (Prilosec) Use of rectal thermometers

How Infection Develops Fewer than 3% of healthy adults carry C. difficile as part of their normal intestinal flora.4 When infections occur, they are the result of ingesting C. difficile spores found in the environment. Studies to determine the infective dose of C. difficile with antibiotic-treated animals indicate that ingesting as few as two spores may be enough to cause disease.9 Ingested spores of C. difficile can survive gastric acid and readily pass through the stomach. When the spores are exposed to bile acids in the small intestine, they germinate and produce two potent enterotoxins: toxin A and toxin B. Both toxins then seriously damage the lining of the JUNE 2019 | OR TODAY |

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continuing education colon (mucosa), resulting in inflammation, hemorrhage and necrosis.10 About half of the patients who become colonized with C. difficile do not develop symptoms.5 For those who do, symptoms can appear as early as one day after exposure to antibiotics or up to three months after antibiotic therapy has been completed.5 For mild to moderate CDI, the most common symptom is lower abdominal cramping pain without fever. In these cases, diarrhea is usually mild, with up to 10 loose, watery stools per day.10 For moderate to severe cases of CDI (colitis without pseudomembrane formation), symptoms include profuse watery or mucoid, greenish, foul-smelling diarrhea (10 to 15 stools per day) that may contain blood. In addition, abdominal distention, anorexia, cramps, fever, leukocytosis, malaise and nausea often occur, and dehydration is common. Diarrhea can be unexpected and explosive, resulting in significant shedding of C. difficile spores into the environment. Very severe cases of CDI (pseudomembranous colitis) present with the same clinical symptoms as severe colitis; however, endoscopic examination of the colon in these cases shows inflamed mucosa studded with raised yellow and off-white plaques. The plaques often cover large portions of the mucosa and easily slough off, giving rise to the term “pseudomembrane.”11 Fulminant pseudomembranous colitis with prolonged ileus, megacolon and perforation can occur. Diarrhea may occur from paralytic ileus and an enlarged dilated colon (toxic megacolon). The only symptoms may be a high fever, severe lower or diffuse abdominal pain, tenderness, distention, and a moderate or marked leukocytosis. There may be signs and symptoms of bowel perforation with severe point tenderness and rebound tenderness. Abdominal rigidity,

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involuntary guarding and reduced bowel sounds may also occur. For patients with fulminant pseudomembranous colitis, aggressive therapeutic interventions, including emergent colectomy, are necessary to prevent morbidity and mortality.5 Recurrent CDI occurs in one in five successfully treated patients as early as two weeks to two months after treatment.4,5 Although the exact reasons for relapse are unclear, it may be because of a reinfection with C. difficile or to non-eradicated spores in the colon. Both vancomycin and metronidazole can kill the vegetative (growing, reproducing) form of C. difficile, but neither kills the spores that can germinate after treatment and before the normal colonic flora is restored. Unfortunately, after treatment for the first relapse, some patients will have further recurrences.5 Relapses may also occur because of new C. difficile infections. There are limited data to support the use of probiotics — nonpathogenic bacteria, such as Saccharomyces boulardii and Lactobacillus GG — to prevent primary CDI and a risk of bloodstream infection.5,6

Pinpointing C. difficile Diagnosing C. difficile is based on clinical symptoms supported by endoscopic findings or stool testing for the presence of the pathogen or toxins. C. difficile infection should be suspected in any patient with diarrhea who has received antibiotics in the last three months or whose diarrhea begins 72 hours after hospitalization.5 C. difficile toxin in a stool sample is unstable, yet many rapid laboratory tests target these toxins for identification of infection. One common laboratory test in hospitals to diagnose C. difficile-associated disease is the enzyme-linked immunosorbent assay, which checks for toxins A or B. Laboratory tests of this type can provide results in only a few hours.

The test is hampered, however, by its suboptimal sensitivity of 63% to 94%.6 A two-step test using enzyme immunoassay detection of glutamate dehydrogenase, a C. difficile common antigen, and then a cell cytotoxicity assay or toxigenic culture to confirm glutamate dehydrogenase-positive stool specimens provides more accurate results. Polymerase chain reaction testing is rapid and sensitive.6 The most sensitive manner of identification appears to be specimen culture followed by identification of the toxigenic isolate, but this may require several days for completion. Presently, there is no diagnostic strategy that is 100% accurate in identifying infection with C. difficile, and diagnosis must also take clinical suspicion into consideration.6

Which Therapy is Best? CDI may resolve itself in patients with mild disease if the precipitating antibiotic is discontinued. The decision to treat is based on the severity of the symptoms.6 For patients with moderate to severe diarrhea/ colitis, antibiotic therapy is needed to eradicate C. difficile. The antibiotics used are oral metronidazole (500 mg three times a day for 10 to 14 days) and oral vancomycin (125 mg four times a day for 10 to 14 days).5,6 The two drugs were thought to be equally effective, although it now seems that the rates of CDI response to metronidazole are declining. Nevertheless, metronidazole is still the drug of choice for most patients with mildto-moderate disease, because it is less costly than vancomycin and less likely to promote emergence of vancomycin-resistant enterococci. For severe disease, oral vancomycin should be used in combination with IV metronidazole. As a caution, metronidazole should not be used beyond the first recurrence of CDI or for longterm therapy because of its potential for cumulative neurotoxicity.6 There WWW.ORTODAY.COM

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continuing education

is also concern over treatment failure with the use of metronidazole. Treatment failure increased by 30% over the span of one year.12 In 2001, the U.S. Food and Drug Administration (FDA) approved fidaxomicin (Dificid), a poorly absorbed macrocyclic antibiotic, as a treatment for C. difficile. While fidaxomicin compares to vancomycin in effectiveness for treating CDI, its advantage is that it has less effect on fecal flora, which reduces the recurrence rate. Fidaxomicin acts by inhibiting protein synthesis. It is bactericidal (kills bacteria), whereas vancomycin is bacteriostatic (slows growth of bacteria). It also requires lower minimum inhibitory concentration of the drug and lasts a longer time than vancomycin and metronidazole.12 Because it has less of an impact on the patient’s normal GI flora, fidaxomicin decreases the likelihood of colonization and recurrence. It also inhibits sporulation, which can in turn decrease the shedding of spores into the environment.12 Although fidaxomicin has advantages over metronidazole and vancomycin, the cost of the medication should be considered when determining the true benefit. Recommendations for use include targeting it for those at high risk of recurrence. Other factors include age older than 65 years, underlying illness, infection with the hypervirulent strain, prolonged hospital exposure, need for continued antibiotics, need for proton pump inhibitors, very high white blood cell count, or very low lymphocyte count.12 Another treatment option, currently under investigation, is fecal microbiota transplant (FMT).12 FMT uses stool specimens from healthy donors as therapy to help the person with recurrent C. difficile re-establish his or her normal GI flora. The donor feces are administered via duodenal infusion or bowel lavage. Cure rates as high as WWW.ORTODAY.COM

81% have been reported. The FDA has issued guidance on the appropriateness of FMT for people who are not responding to traditional therapies.13 The use of FMT is not widespread at present, but practitioners should be well-informed to answer patient questions about this treatment. Because feces are considered a biologic, healthy stool, donors undergo a rigorous screening process much like that of blood donors. Tests include:14 Human immunodeficiency virus (HIV) types 1 and 2: antibody Hepatitis A: immunoglobulin (lg) M, IgG Hepatitis B: hepatitis B surface antigen (HBsAg) Hepatitis C: antibody Salmonella, Shigella, and Campylobacter: routine bacterial stool culture Treponema pallidum: rapid plasma reagin test (RPR; if results are positive, those findings are confirmed by antibody testing) Ova and parasite: fecal screen Carbapenem-resistant Enterobacteriaceae: screening culture Vancomycin-resistant Enterococcus: screening culture Helicobacter pylori: stool antigen Clostridium difficile: polymerase chain reaction (PCR) The donated specimen is processed and prepared for transplant using a specified protocol. Follow-up is recommended four to six weeks following transplantation. Antidiarrheal agents, such as diphenoxylate hydrochloride and atropine sulfate (Lomotil) or loperamide (Imodium), and narcotic analgesics should be avoided. These agents may delay clearance of toxin from the colon and cause additional colon injury, which may lead to ileus and toxic dilation. Patients who develop fulminant colitis require admission to the ICU and may need an emergency colectomy because of severe ileus with dilated colon or impending perforation.4 Fecal

bacteriotherapy, or fecal transplant, is the transfer of donor gut bacteria in feces to the bowel of a CDI patient.6 This potential therapeutic option restores the balance of normal flora in the GI tract of the patient with C. difficile. Before transplant, donor stool is tested for pathogens. It is then transplanted into recipient via a retention enema, colonoscopy or nasogastric tube. Some systematic studies have found the success rate to be greater than 92%.6

Fighting Infection Preventing infections with C. difficile in hospitals and long-term care facilities is a challenge for many reasons. Many hospitalized patients are treated with antibiotics, which makes them more susceptible to colonization or infection with C. difficile. Asymptomatic colonized patients, who are fecal excretors (have C. difficile in their feces), may be an important hidden reservoir of the bacteria. The bacteria/spores excreted by these patients can be transmitted throughout a facility by contaminated hands of healthcare workers and on shared patient-care equipment. There is no way to determine how many asymptomatic carriers are present in a hospital or the colonization rate with C. difficile, because it is not appropriate to test all patients. It is known that when patients become colonized, at least two-thirds do not develop clinical symptoms. What is not known is whether colonization is temporary or permanent. Treatment of asymptomatic patients to eradicate carrier status is also not recommended.5,6 Many common hospital disinfectants cannot kill the C. difficile spores found in rooms of colonized or infected patients; however, diluted sodium hypochlorite (bleach) or an EPA-approved sporicidal disinfectant is effective for cleaning contaminated surfaces in patient rooms.5 Other methods include “touch-free” cleaning with automated equipment, such JUNE 2019 | OR TODAY |

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continuing education as ultraviolet radiation technology and hydrogen peroxide vapor.8 The alcohol gel hand rubs (sanitizers) used in many hospitals to disinfect hands do not kill C. difficile spores and neither does soap and water. Although there are no studies that have shown an increase in C. difficile with the use of hand sanitizer or a decrease with the use of soap and water, it has been shown that soap and water is more effective in removing spores from the hands.8 It is also important to teach the patient and family proper techniques for handwashing. During outbreaks, handwashing with soap and water is recommended for those caring for suspected or confirmed patients. Healthcare workers should also wear clean, nonsterile gloves when caring for patients and when touching patient items.5,8 We must be sure to take the precautions below to prevent the spread of C. difficile:5,6,8 Antibiotics associated with high rates of CDI should be avoided. All healthcare workers, including dietary, housekeeping and maintenance, should receive information about the transmission of C. difficile and take precautions to interrupt transmission. As soon as CDI is suspected or identified, patients should be placed on contact precautions in a private room with a private bathroom. If private rooms are not available, patients can be placed in rooms with other patients with CDI (cohorted). If bathrooms are shared with non-infected patients, an individual commode chair should be used. Signs or placards indicating the precautions should be placed on the door of any room with a suspected or confirmed CDI patient. Healthcare workers should use gowns and gloves for all contact with suspected or infected patients. Gowns and gloves should be put on before entering the room of confirmed patients and removed when exiting. This practice prevents healthcare workers from carrying the pathogen on their clothes to other patients. When indicated, healthcare workers should wash their hands with soap and water for at least 15 seconds to remove C. difficile spores. Disposable or dedicated equipment should be used for each suspected or confirmed CDI patient. Patient-care equipment, such as blood pressure cuffs, stethoscopes and thermometers, should remain in the patient’s room and not be shared with other patients. Patient rooms and medical equipment should receive careful cleaning/disinfection with an agent capable of destroying C. difficile and its spores. Hypochlorite-based disinfectants or household bleach (1/4 cup household bleach to 1 gallon of water) can be used to disinfect environmental surfaces. Warning: Never mix chlorine bleach solution

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with other cleaning solutions or detergents containing ammonia; this mixture may produce highly toxic vapors. An EPA-approved sporicidal disinfectant may be used according to manufacturer’s directions. Rooms should be cleaned thoroughly with attention to high-touch surfaces as per policy and when a patient with a CDI is discharged. Throw away all disposable items that cannot be disinfected. Because of the increased incidence and severity of CDI, the CDC recommends direct surveillance and reporting of healthcare-associated CDIs. To implement surveillance, the following definitions have been developed. Hospitals need to remain on guard for the virulent strain of C. difficile. All healthcare professionals play a vital role in preventing transmission of this pathogen to our patients when we pay careful attention to infectioncontrol measures and ensure that everyone in contact with infected patients follows contact (barrier) precautions.

Case Definition for CDI8 · Diarrhea: unformed stools that take the shape of the specimen collection container — or toxic megacolon — abnormal dilation of the large intestine documented radiologically · Stool sample — positive assay for C. difficile toxin A or B, or a positive stool culture with a toxin-producing C. difficile organism · Pseudomembranous colitis seen during endoscopic examination or surgery · Pseudomembranous colitis seen during histopathological examination

Definition of CDI Recurrence · Two episodes of CDI in the same patient that occur fewer than eight weeks apart are considered a relapse. It is not possible in clinical practice to determine whether the second occurrence is a relapse with the same strain or a reinfection with a different strain.

Definition of Severe CDI

Severe CDI: Patients who meet any of the criteria below within 30 days after CDI diagnosis: · History of admission to an ICU for complications associated with CDI (e.g., shock requiring vasopressor therapy) · Surgery (colectomy) for toxic megacolon, perforation or refractory colitis · Death caused by CDI within 30 days after symptom onset (e.g., listed on death certificate or recorded in medical record by clinician caring for patient)

EDITOR’S NOTE: Connie C. Chettle, MS, MPH, RN, past author of this educational activity, has not had the opportunity to influence the content of this version. Barbara Barzoloski-O’Connor, MSN, RN, CIC, is the infection-control manager at Howard County General Hospital in Columbia, Md. WWW.ORTODAY.COM

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References 1. Antibiotic/antimicrobial resistance: antibiotic resistance threats in the

8. APIC implementation guides: guide to preventing Clostridium difficile

United States, 2013. Centers for Disease Control and Prevention Web site.

infections (2013). Association for Professionals in Infection Control and

http://www.cdc.gov/drugresistance/threat-report-2013. Updated April 10,

Epidemiology Web site. https://apic.org/Professional-Practice/Implemen-

2017. Accessed June 1, 2018.

tation-guides. Accessed June 1, 2018.

2. Sekulovic O, Meessen-Piard M, Fortier LC. Prophage-stimulated toxin

9. Slimings C, Riley TV. Antibiotics and hospital-acquired Clostridium

production in Clostridium difficile NAP1/027 lysogens. J Bacteriol.

difficile infection: update of systematic review and meta-analysis. J Anti-

2011;193(11):2726-2734. doi: 10.1128/JB.00787-10.

microb Chemother. 2014;69(4):881-891. doi: 10.1093/jac/dkt477.

3. Deshpande A, Pimentel R, Choure A. Antibiotic-associated diarrhea

10. Otter J. What does it take to prevent the transmission of C. difficile

and Clostridium difficile. Cleveland Clinic Center for Continuing Education

from environmental surfaces? Reflections on Infection Prevention and

Web site. http://www.clevelandclinicmeded.com/medicalpubs/disease-

Control Web site. https://reflectionsipc.com/2013/02. Published February

management/gastroenterology/antibiotic-associated-diarrhea/Default.

25, 2013. Accessed June 1, 2018.

htm. Published June 2014. Accessed June 1, 2018. 4. Nearly half a million Americans suffered from Clostridium difficile infections in a single year. Centers for Disease Prevention and Control Web site. https://www.cdc.gov/media/releases/2015/p0225-clostridiumdifficile.html. Accessed June 1, 2018. 5. Dubberke ER, Carling P, Carrici R, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(6):628-645. doi: 10.1086/676023.

11. Farooq PD, Urrunaga NH, Tang DM, von Rosenvinge EC. Pseudomembranous colitis. 2015;61(5):181-206. doi: 10.1016/j.disamonth.2015.01.006. 12. Mullane K. Fidaxomicin in Clostridium difficile infection: latest evidence and clinical guidance. Ther Adv Chronic Dis. 2014;5(2):69-84. doi: 10.1177/2040622313511285. 13. Enforcement policy regarding investigational new drug requirements for use of fecal microbiota for transplantation to treat Clostridium difficile infection not responsive to standard therapies: draft guidance for

6. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines

industry. U.S. Food and Drug Administration Web site. https://www.fda.

for Clostridium difficile infection in adults: 2010 update by the Society

gov/downloads/biologicsbloodvaccines/guidancecomplianceregulatory-

for Healthcare Epidemiology of America (SHEA) and the Infectious

information/guidances/vaccines/ucm488223.pdf. Published March 2016.

Diseases Society of America (IDSA). Infect Control Hosp Epidemiol.

Accessed June 1, 2018.

2010;31(5):431-450. doi: 10.1086/651706.

14. Tauxe WM, Dhere T, Ward A, Racsa LD, Varkey JB, Krafy CS. Fecal

7. Lessa FC, Gould CV, McDonald LC. Current status of Clostridium dif-

microbiota transplant protocol for Clostridium Difficile infection. Lab Med.

ficile infection epidemiology. Clin Infect Dis. 2012;55(Suppl 2):S65-S70.

2015;46(1):e19-e23. doi: 10.1309/LMCI95M0TWPDZKOD.

doi: 10.1093/cid/cis319.

Clinical Vignette A 67-year-old man was admitted to the hospital with pneumonia and an acute exacerbation of his asthma. He was placed on oxygen, treated with a beta-adrenergic agonist, and started on systemic corticosteroids. He also started a 10-day course of moxifloxacin (Avelox). While hospitalized, he continued taking his medication for blood pressure, lisinopril (Zestril), and for ulcers, lansoprazole (Prevacid). After six days in the hospital, the patient was well enough to go home. He was told to taper his asthma medication as directed and to continue taking the moxifloxacin for four additional days. Five weeks postdischarge, after three days of severe abdominal cramps and eight to nine watery, greenish, foul-smelling stools each day, the patient presented to the ED. Stool specimens tested positive for C. difficile and the patient was readmitted to the hospital.

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1. Which risk factor for CDI did the patient have?

a. Age older than 65 and severe underlying illnesses b. Previous hospitalization and proton pump inhibiters c. Avelox, proton pump inhibitors, and hospitalization d. All the above 2. When the patient was admitted to the floor, the nurse who was to care for him paged the infectioncontrol nurse to ask which precautions she should take to prevent transmitting C. difficile to her other patients. The infection-control nurse told her to:

a. Disinfect her hands after each patient encounter with the waterless, alcohol-based hand sanitizer b. Wipe down the electronic rectal thermometer and blood pressure cuff used on the patient with C. difficile with a quaternary ammonia compound (hospital disinfectant) JUNE 2019 | OR TODAY |

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continuing education before using equipment on her other patients c. Wash her hands with soap and water for at least 15 seconds to remove C. difficile spores physically d. Keep the door to the patient room closed so airborne spores will not spread throughout the hospital 3. The nurse wanted more information about C. difficile infections. When the patient’s physician came to the floor, she asked if he would talk to the nurses about CDI at a staff meeting later that afternoon. At the staff meeting, the physician told the nurses that:

a. A new, more virulent strain of C. difficile (BI/NAP1/027) emerged in 2000. This strain produces 16 times more toxin A and 23 times more toxin B than the strains in the 1980s and 1990s. b. The new strain colonizes the respiratory system after normal flora has been disrupted by antibiotic therapy. It causes the lungs to fill with fluid, leading to shock and death. c. More than 90% of patients carry C. difficile as part of their normal intestinal flora. d. Patients with C. difficile need special handling to prevent transmission of the bacteria to other patients. Nurses should put on gowns, gloves and N95 respirators before entering the room of infected patients. Before leaving the room, they should carefully disinfect their hands with waterless, alcohol-based hand sanitizers. 4. At the staff meeting, one of the nurses asked the physician to explain why diarrhea caused by C. difficile (BI/NAP1/027) is more worrisome than diarrhea caused by other microbes. Which reason given by the physician is correct?

a. Patients with fulminant pseudomembranous colitis due to C. difficile infections may need an emergency colectomy because of severe ileus or impending perforation. b. There is no effective treatment for C. difficile infections. c. CDI is readily transmissible through the airborne route. d. C. difficile is difficult to distinguish from other GI microbes.

Clinical VignettE ANSWERS 1. D — All are risk factors for CDI, including age, severe underlying illnesses, and the use of proton pump inhibitors, such as lansoprazole. Also, in the United States, 10% of patients (3 million) hospitalized for more than two weeks become infected with C. difficile. Exposure to antibiotics is a risk factor for developing CDI. 2. C — Alcohol-based hand sanitizers are not effective against spore-forming bacteria and soap and water are often recommended for spore removal. 3. A — The new strain of C. difficile appeared in 2000. The disease caused by the strain is more severe and more refractory to therapy. It also has a higher relapse rate. 4. A — C. difficile infections can result in the need for emergency colectomy as it may cause severe ileus and lead to bowel perforation.

46 | OR TODAY | JUNE 2019

CE362-60

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 6/15/2020 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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SPEAKER SPOTLIGHT In 2005-06 I was national President of the Association of periOperative Registered Nurses (AORN). Our prime initiative that year was medication safety. We had a comprehensive medication toolkit to assist practitioners with implementation of evidence-based safe medication preparation and administration. As part of a national rollout campaign there was a TV camera crew filming medication preparation during a surgical procedure at the hospital where I was Director of Surgical Services. I was overseeing the cameraman for patient confidentiality appropriateness when I noted that the RN circulator was called from the bedside. The patient appeared anxious so I stepped up, took his hand and told him the surgeon was minutes away and that I would keep him comfortable and we would wait together. The patient immediately stopped moving and relaxed. What followed was a great “ah ha” moment for me. The media person waiting out of the patient’s view immediately honed in and was photographing the patient and my hands. He pointed out with his camera the difference being made in that room by one nurse who assessed the patient’s anxiety, communicated to the patient what was happening, offered the comfort of waiting together and allayed the patient’s anxiety. Perhaps it took the photographer’s eye to see the visual symbol of all the nursing expertise in holding a patient’s hand. A simple act that we, as Registered Nurses, perform daily but there was much more assessment, planning, and communication happening during that compassionate care act and it took a photographer’s eye to point it out. I am so proud to be among the many hand holding RNs that give competent, safe, quality care to patients across this globe. •

SHARON A. MCNAMARA,

Sharon A McNamara RN, BSN, MS, CNOR Perioperative ConsultantOR Dx + Rx Solutions for Surgical Safety

AUGUST 18-20 | LAS VEGAS, NV

RN, BSN, MS, CNOR

Find out more about Sharon and her experience in patient care as she presents, “Leadership Across the Generations” and “Sharps Safety — Are We on the Cutting Edge?” at the 2019 OR Today Live Surgical Conference.

Bringing Shadow Behavior into the Light of Day by Phyllis S. Quinlan, PhD. RN-BC

www.ortodaylive.com

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.

This book provides healthcare leaders with a guideline for the assessment and management of the disruptive behaviors of bullying and incivility. It is time to definitively address the behaviors that lurk in the shadows and undermine RN and other professional caregiver’s vitality and resilience.

Purchase hard copy at mfwconsultants.com/product-category/book3 • Download Kindle version from amazon.com

48 | OR TODAY | JUNE 2019

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HAIs SSIs

Despite the renewed attention that has been focused on the problem of healthcare associated infections (HAIs) and surgical site infections (SSIs) in recent years, the number of infections occurring remains alarmingly high. Approximately 300,000 SSIs still occur annually in the U.S., resulting in an estimated 9,000 patient deaths per year. SSIs occur in 1.9 percent of surgical patients and are associated with a mortality rate of 3 percent. Also, 75 percent of SSI-associated deaths are directly attributable to the SSI. In addition, 800 hospitals will be paid less by Medicare this year due to high infection rates and patient injuries. This is the highest number since the Hospital Acquired Conditions Reduction Program was launched five years ago. Even worse, 110 hospitals are being docked for the fifth straight year.

Achieving a Zero Patient Infection Rate “While progress has been made in recent years in decreasing HAIs and SSIs, the only ‘acceptable’ number of infections is zero, even if this is a theoretical goal,” says Constance J. Cutler, MS, BS, BSN, RN, CIC, FSHEA, FAPIC, the president and CEO of Chicago Infection Control Inc. “In my opinion, prevention of infections has always been an important patient safety initiative,” Cutler adds. “If an HAI happens to you or your loved one, you wouldn’t be satisfied with ‘our infection rates are below the national average’ as a response.” The most common HAIs and SSIs remain staph infections of surgical sites, including infection with MRSA WWW.ORTODAY.COM

"THE ONLY ‘ACCEPTABLE’ NUMBER OF INFECTIONS IS ZERO." ConstancE J. Cutler

(Methicillin resistant Staphylococcus aureus), says Cheron Rojo, AA, CRCST, CIS, CER, CFER, CHL, clinical education coordinator with Healthmark Industries. “In addition, endoscope-acquired infections are becoming more common – they continue to be reported in the news and to the FDA,” adds Rojo. “This type of cross-contamination can lead to multiple drug-resistant infections in patients and is associated with high morbidity and mortality.” Linda Homan, RN, BSN, CIC, senior manager of clinical affairs with Ecolab Healthcare, breaks down the types of HAIs in more detail. According to Homan, pneumonia and SSIs are the most common HAI (21.8 percent each), followed by gastrointestinal infections (17.1 percent). Meanwhile, Clostridioides difficile (formerly Clostridium difficile) is the most commonly reported pathogen, causing 12.1 percent of all HAIs. “Surgical site infections result from the introduction of bacteria into the sterile surgical site,” says Homan. “The likelihood that these bacteria will go on to cause infection is impacted by the patient’s co-morbidities, the type of surgery performed, and other factors such as environmental hygiene, normothermia, ventilation, antimicrobial prophylaxis and glucose control.”

Causes of Infections Rojo says that a common cause of HAIs and SSIs remains improperly cleaned instrumentation and medical devices. “These much-needed surgical tools often have very cumbersome and daunting cleaning, disassembly, testing and reassembly instructions for use (IFUs),” he says. “These IFUs must be carefully followed in order to produce a product that’s safe for patient use.” According to Deborah L. Spratt, MPA, BSN, RN, JUNE 2019 | OR TODAY |

CNOR, NEA-BC, CHL, the executive director of perioperative services at University of Rochester St. James Hospital, most SSIs are caused by the patient’s own flora. “Therefore, it’s important that proper prepping and draping techniques be used in the OR,” says Spratt. “The second most common cause of SSIs is bacteria on the hands of caregivers, so hand hygiene should be performed before gloves are donned and again after gloves are removed.” At the last facility where she worked, Spratt says she and her infection preventionist worked with a multidisciplinary team on a project focused on decreasing SSIs. “We implemented a bundle that began preoperatively in the surgeon’s office by providing education and CHG soap for showers, along with CHG cloths to wipe the incision site on the day of surgery,” she says. “In the preop area, we checked glucose levels, kept patients warm and used a CHG cloth again on the site,” says Spratt. “Preop antibiotics began circulating in the bloodstream within an hour before incision and then redosing occurred in the OR as appropriate." “We also enforced hair coverage, OR prep using sterile gloves and covered arms and clean closure technique,” she adds. Spratt is a strong believer in patient education before surgery, on the day of surgery and post-operatively as a key component of reducing infections. “This should include an assessment of the patient’s home environment,” she says. “A home with no running water or a patient with poor personal hy-

giene will contribute to the infection risk factors.”

Preventing Infections Homan says that while emphasis is rightly placed on aseptic technique during surgery to prevent contamination of the sterile field, it’s also important to consider the cleanliness of the environment. “Contaminated equipment and surfaces harbor bacteria that can contaminate the sterile field or the hands of surgical personnel,” she says. Homan acknowledges that the pressure to turn rooms over quickly between cases is real. “Most perioperative staff members have had no formal

infection explains how bacteria get from the site where they normally live and may cause a surgical site infection,” Cutler says. “For example, more facilities today are using a product that is applied to the nasal mucosa of any patient with an implant to decolonize patients unknown to be colonized with MRSA,” Cutler adds. “Thorough bathing of patients with CHG cloths kills MRSA on the skin and would also lessen the risk of infection.” Rojo lists a few other infection prevention steps that he believes could help prevent HAIs and SSIs. “First of all, the correct cleaning tools, testing equipment and organization tools are needed to ensure clean and functional instrumentation and medical devices,” he says. These include cleaning brushes, laparoscopic testers, multi-pouches and tip protectors. “Hospitals also need to invest in a more robust inventory of instrumentation and medical devices to meet the realistic demands of the typical day-to-day OR volume,” Rojo adds. “Effective staff communication and education on instrument tray and medical device processing, and the time considerations that go along with them, is also necessary.” Finally, Rojo stresses the importance of staff training when it comes to infection prevention. “Initial and continuous training with competency verification for sterile processing personnel on both new and existing instruments and medical devices is paramount,” he says.

"THE SECOND MOST COMMON CAUSE OF SSIs IS BACTERIA ON THE HANDS OF CAREGIVERS.”

Constance J. Cutler

52 | OR TODAY | JUNE 2019

Linda Homan

Deborah L. Spratt

training on the process of thoroughly and quickly cleaning and disinfecting rooms,” she says. “New evidence on the importance of environmental hygiene has been published in the last decade, and professional associations such as AORN and AHE now have evidence-based guidelines for environmental hygiene in the operating room,” Homan adds. Cutler concurs: “One important thing OR personnel can do to prevent infections is to use external guidelines from AORN, the CDC and other organizations to create their internal policies,” she says. “All health care personnel, including surgeons, should be held to the facility’s policies and be able to speak to and refer to them easily.” She emphasizes the importance of understanding the chain of infection when it comes to limiting the transmission of bacteria that lead to infection. “The Deborah L. Spratt chain of

Zero Tolerance of Infections Cutler takes a zero tolerance view toward infections and stresses the importance of controlling the things that can be controlled. “This includes using CHG bathing and following appropriate antibiotic timing,” she says. “These things should be in place and followed 100 percent of the time for every patient, with no exceptions.” WWW.ORTODAY.COM

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SPOTLIGHT ON:

Brenda Muchel l i,

RN, BSN

BY MATT SKOUFALOS

renda Muchelli calls herself “a second-degree nurse.” Like many in the field, medicine wasn’t her first vocational choice – at least, not human medicine. Muchelli’s first degree was in zoology, and her first assignment was at the nonprofit Cape May County Park and Zoo in Cape May Court House, New Jersey.

“I went to college to be in the animal field,” she said. “I was a zookeeper, a vet tech; I was kind of considering vet school.” “And then, in my mid-to-late 20s, my Brenda Muchelli (left) decided to become a nurse after her father (right) had a heart attack. dad went into cardiac arrest at work on his 54th birthday,” Muchelli said. “I was some of the staff into whose care she was cept it, they understand.” his emergency contact. They called me at entrusted. So, Muchelli went back to school. She work and said, ‘Your dad stopped breath“I said, ‘OK, that’s enough,” she enrolled in an accelerated nursing degree ing.’ I blacked out.” recalled. at Rutgers University in Camden, New Muchelli’s father was transported There were other reasons, too. ZoolJersey. Within the course of an intense to one local hospital, and then another, ogy was only allowing her to earn a $9 year, she had completed the program before he was stabilized. It took him a hourly wage, and after transitioning to a requirements, one of a small class of 30 year to recover, but he’s since returned veterinary technician role, the pay rate new nurses. to work, and is “back to everything he’s didn’t improve much. Plus, working in “School was extremely stressful,” done before,” she said. That experience an animal hospital meant occasionally Muchelli said. “We weren’t allowed to made Muchelli reconsider her conceneuthanizing animals, which was emotion- work, so I had to take out a bigger loan. tration in animal medicine; another ally taxing. Four classes a week and 30 hours a week one confirmed the impulse. While her “I would cry like they were my own in the hospital … I lost my mind a little grandmother was hospitalized during a [pets],” Muchelli said. “With people, it’s a bit when I was going through that.” bout with lung cancer, Muchelli was put little bit easier; a lot of them understand “[But] we all had the same goal,” she off by the way her relative was treated by what’s happening. Even if they don’t acsaid. “We wanted to get to where we

54 | OR TODAY | JUNE 2019

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Brenda Muchelli is seen with her three brothers.

could help people. We knew how important it was, so it should be that difficult. We just put our heads down and went through it.” When it was all done, “the only place I wanted to go was the ICU,” Muchelli said. Upon graduation, she was hired by Cooper University Hospital, also in Camden: the very institution that had saved her father’s life. She’d completed a rotation in its ICU in the first three months of her schooling; as a member of the staff, she worked there for three years before transferring to the post-anesthesia unit. “It’s still critical care, but a little bit happier,” Muchelli said. “You recover people from surgery, but a lot of them get better and go home. I kind of get the

Brenda Muchelli is seen with her husband, Jonathan Muchelli. WWW.ORTODAY.COM

best of everything. Even though the stress level is there, it’s much less, and it’s not nearly as sad.” Muchelli views patient advocacy as a major part of her responsibilities on the job. She related the story of a terminally ill patient who kept telling her caregivers that she wanted to go home and be comfortable instead of subjecting herself to additional tests, treatments or procedures. “They wanted to do all these things for her,” Muchelli said. “I went in one morning and said, ‘She doesn’t want it. She wants to die in peace.’ The attending physician came up to me and thanked me for doing that. He looked at his fellow under him and said, ‘This is why you have nurses.’ ” “I like feeling like I’m doing something to make these people feel human,” she said; “making them laugh when they feel like crap; making the doctors hear them when they don’t feel like they’re heard.” Helping patients to feel understood, and helping her coworkers to advocate for their patients and themselves, is a very difficult and persistent challenge. Muchelli describes “a lot of extreme emotion involved,” and when people get overloaded, they shut down mentally. She also charts some expanded practice areas at her hospital, including stroke care and a partnership with MD Anderson Cancer Center, as evolving its ICU into “an everything ICU.” “The typical patients we never had room for, so it was very taxing because

they would all be comfort care,” Muchelli said. “It got to a point where my anxiety and stress was so bad because I was taking it home with me.” To cope, she took up running. A former high school athlete, the exercise she once hated is now the best thing for her stress. Focus on breath and movement helps (as does the occasional glass of wine), but in general, Muchelli said she can work things out in her head when she’s running that don’t make sense when she’s sitting. And in the workplace, she’s come to rely on the camaraderie of her colleagues, who find themselves in similar circumstances often. “A lot of stuff that’s traumatic or sad, we joke about it, and that’s normal,” Muchelli said. “It’s a way to do it every day. We pretty much debrief each other. I think the only people who get it are the ones involved.” Just as her career goals have evolved from zoology to intensive care to postanesthesia care, Muchelli believes she will advance her education further, with sights set on becoming a nurse practitioner or a nurse anesthetist. She’s consulting with nurses who’ve done either or both. But on whichever path her work takes her, Muchelli will remain committed to patient care and patient advocacy. “I feel like everybody who helped my dad was so good to us before I even knew anything in the medical field,” she said. “I want to do that for the patients and their families too.” JUNE 2019 | OR TODAY |

OUT OF THE OR fitness

Body Weight Workouts for the Win! By Miguel J. Ortiz he best exercise equipment you will find in any gym will always be your body. So, technically speaking, you may not need the gym. It depends on your goals, but the like-minded motivation and assistance from a fitness professional can help tremendously. Your body is an incredible tool and you can learn a lot from it, if you’re paying attention. So, what are some good movement patterns to do at home and how can we use them to help us with our goals? Let’s start with 7 basic movements patterns – squat, lunge, bend, rotate, gait, push and pull. Let’s look at how these movements assist in some quality workouts as well as help direct attention to some needed areas.

When you hear the word gait, that means it’s a cyclical movement pattern, think cardio. Running, rowing, jump rope, bicycle riding, elliptical, swimming, etc. are all examples of gait movement patterns. This movement pattern is great for a warm up, general calisthenics, a long run or a cool down. It is a common go-to for all exercise enthusiasts. The squat, I would have to say, is by far one of the most important movement patterns. So, do you know who has the best squats? Most people wouldn’t guess this, but children have the best squat

56 | OR TODAY | JUNE 2019

pattern. Why? Because they learn to pick everything up using their legs. Bending over to pick things up only starts to occur when we get lazy or a lack of activity has started to become prevalent. We sit and use our legs every day, so this movement pattern is never something to ignore. Next, let’s look at the lunge. Depending on the person, a lunge can be a little advanced. You might need some assistance. If you are practicing lunges at home, you might want to start stationary or simply do a step-up. This can assist with future lunge patterns and more advanced movements as you progress. Bend or hinge movements will cover two different categories. It is very important to understand how to separate the two. It’s perfectly fine for your back to bend, but take caution as you don’t want to be bending during heavy strength movements as injury may occur. Most of your other bend movements will happen during stretching, yoga, core, crunches, leg lifts and Pilates exercises. Rotate is another movement pattern that will also cover a lot of core exercises and the same concepts need to be applied when keeping the back straight. A good example would be a plank rotation or a V-sit twist. Both exercises are in a stationary position, both require you to keep your back straight and deal with rotation. Push and pull movements are next on the list. These are pretty self-explanatory as your either pushing away or pulling

something toward you. Push-ups, shoulder press (push) and triceps push downs are good push examples. Pull examples are pull-ups, bicep curls (pulls) and rows. So, now that we reviewed all of our movement patterns, let’s put them together and try a fun little home workout. I suggest three rounds of the following for time. This way you can measure progress the next time you complete this workout. 1. 20 Air Squats 2. 10 Push-ups 3. 20 Lunges 4. 20 leg lifts 5. 30 Jumping jacks 6. 40 Bicycle Crunches Have fun with your home workout and don’t be afraid to take these exercises outside. Want to mix it up with your normal jogging routine? Well, maybe you decide to do 5 push-ups or 10 squats every 10 minutes of running and see what that will do to your workout. Enjoy your body for its ability to be pushed to the limit and never doubt yourself. You will never know what you can accomplish until you try. 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.

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JUNE 2019 | OR TODAY |

SPEAKER SPOTLIGHT I’ve been coaching professionally for 20 years. In the beginning, my services centered on conventional issues such as assistance deciding on the right graduate program, resume writing and interview preparation. About 10 years ago, I received a call from a nurse requesting my help finding a position that did not require direct patient care. I immediately assumed that she was either battling an illness or challenged by an ergonomic injury. When I asked her to share her physical stamina without divulging too much personal health information, she laughed and said, “I’m strong and healthy! I just don’t want to take care of patients any more and if I never have to work in a hospital again, that would be OK too.” It was then that I realized, I was speaking to my first client battling compassion fatigue. Since then, 85% of individuals seeking my assistance are struggling with role transition, compassion fatigue or bullying and incivility at work. The mission and goal of my coaching practice is now re-focused on working with professional and family caregivers to build their resilience and reconnect with the joy of what they do. I am also devoted to working with leaders and administrators in the creation of healthy work environments. • Phyllis S. Quinlan, PhD, RN-BC Founder, President of MFW Consultants To Professionals, Inc.

AUGUST 18-20 | LAS VEGAS, NV

PHYLLIS S. QUINLAN, PHD, RN-BC

Find out more about Phyllis and her experience in coaching as she presents, “Understanding and Effectively Managing Bullying & Incivility in Your Perioperative Department” and “Emotional Intelligence at Work: Focus on social awareness and relationship management” at the 2019 OR Today Live Surgical Conference.

www.ortodaylive.com

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OUT OF THE OR health

Kinhin: Calm Your Mind While Stimulating Your Soles By Marilynn Preston ave you ever tried walking meditation? It’s a gentle and giant step into the world of Zen. And in case you’ve just returned from planet Elsewhere, Zen is trending big here on Earth. There are Zen retreats, Zen smoothies, Zen comics, Zen methods of diapering and accounting and an actual book called “Zen and the Art of Casino Gaming.”

“Zazen” is the Japanese word for seated meditation, and kinhin is walking meditation. Both are proven methods for quieting the mind. Kinhin is a simple practice that gives you all the benefits of seated meditation – increased energy, equanimity, awareness – with zero risk of falling asleep. “Meditation is simple but not easy,” says Henry Shukman, head teacher at the Mountain Cloud Zen Center in Santa Fe, New Mexico, who taught walking meditation to me and a tentful of others at the Esalen Institute some time ago. “Walking meditation is a chance to tune into our own experience,” Henry explained, “to be in this place, to touch this Earth, to be right here, right now.” It’s from that place of total presence that a sense of well-being flows. Neuroscientists have proven this with innovative brain imaging studies. When you stop dwelling on the past and future and focus on living in the present moment, stress eases, your fears and anxieties dissolve, and kindness and compassion rise to the surface. All that and physical activity, too, and you don’t have to be Buddhist to benefit. Here’s a summary of Henry’s WWW.ORTODAY.COM

teachings about walking meditation:

STEP 1. WALK INTO NATURE Sometimes, walking meditation is done inside a Zen temple – as a break from long periods of sitting meditation – but doing it outside in nature offers special rewards. Wear comfortable shoes and pick an outdoor path that is safe and unencumbered, the quieter the better.

STEP 2: ARRANGE YOUR HANDS There is a Zen way of doing just about everything – from washing the dishes to bathing your dog – so it’s no surprise that walking meditation in Henry’s Sanbo Zen lineage has rules about how to hold your hands. “You put your right hand around your right thumb and use the left hand to gently press your right hand against your solar plexus,” Henry demonstrated. “That’s the Zen way.” Is it the only way? Of course not. It’s so totally not Zen to dictate to people what they can and cannot do. Your solar plexus, in case you’re wondering, is right in the middle of your upper torso, just below the diaphragm. It’s the energetic center – or chakra – of strength, confidence and joy.

STEP 3: MIND YOUR POSTURE Walk mindfully, in silence, with an upright spine and a slight chin tuck. Keep your eyes open and lowered, but not in a way that makes your walking unsafe. Walk in a way that feels relaxed and aware, opening up the deepest channels of the body, allowing for a flow of energy up and down the spine, drawing

up from the earth, drawing down from the sky. I know it sounds a little woo-woo, but hey, haven’t lots of things that used to seem woo-woo turned out to be true-true?

STEP 4: DON’T FOCUS ON YOUR BREATH Really? Meditators are always being told to focus on the breath as a way to connect mind and body and sink into the bliss of boundlessness. For our first walking meditation, Henry took us in a different direction. “Let your mind rest in the soles of your feet,” he instructed. Don’t overthink it. Just let go and let it happen, walking at a comfortable pace, focusing your mind’s eye on the bottom of your feet. When you lose focus and your mind begins to wander to the future or the past – just as it does in sitting meditation – you simply acknowledge the lapse, return your awareness to the soles of your feet and keep it there until your final step.

STEP 5: NOTHING TO GAIN At the end of our refreshing and revelatory 20-minute walking meditation, Henry explained a little more about its power. “It’s about being as we are, where we are ... the experience of the now. Our minds grasp for meaning, grasp for understanding ... “There is nothing to understand,” said Henry. “There is just now.” – Marilynn Preston is the author of “Energy Express,” America’s longest-running healthy lifestyle column. For more on personal well-being, visit www.MarilynnPreston.com. JUNE 2019 | OR TODAY |

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OUT OF THE OR EQ Factor

Practicing EQ has Many Benefits, but you Must Want it By Daniel Bobinski esearch involving 200 companies worldwide has revealed that in middle management and technical positions, two-thirds of the difference between average performers and top performers is emotional intelligence. An amazing statistic, right?

The benefits of practicing EQ are also outlined in an article published by “Harvard Business Review,” titled, “Can you really improve your emotional intelligence?” In the opening paragraph, they ask, “Who wouldn’t want a higher level of emotional intelligence? Studies have shown that a high emotional quotient (or EQ) boosts career success, entrepreneurial potential, leadership talent, health, relationship satisfaction, humor, and happiness.” You’d think that everyone would want those benefits, but it’s not always the case. In fact, when technically competent people with average or below-average interpersonal skills get promoted because of their technical skills, EQ might not even be on their radar. Why? Because in many such cases, people think they received their promotion because of how they have been treating people, and not in spite of it. I’ve seen it more than once. TechWWW.ORTODAY.COM

nical experts with poor interpersonal skills get promoted a few times, but then the promotions stop. When that happens, those people often believe others on their team are not working hard anymore, or maybe even that others are trying to sabotage them. As evidenced by abundant research, if people want to get promotions – or start getting promotions again – it helps if they brush up on emotional intelligence and put it in to practice. As the famous motivational speaker Zig Ziglar often said, 80 percent of promotions happen because of good people skills, and only 20 percent because of good technical skills. The first step in improving one’s emotional intelligence is developing a desire to do so. Somehow people need to realize that others have different behavioral styles, and different cognitive styles, too. They also need to realize that not everyone is motivated by the same things that motivate them. They further need to realize that valuing, adapting to and capitalizing on the strengths associated with those different styles is what makes a team effective. There’s also the need to understand that practicing emotional intelligence is a choice. The bottom line here is that people must want to develop their emotional intelligence. If that

desire is not apparent, sometimes a heart-to-heart talk may be warranted. With that in mind, if you think you want to beef up your EQ (and yes, EQ is learnable), why not seek out someone you trust and strike up a conversation about it? If you’re already familiar with EQ and know someone who isn’t (but needs to be), might I suggest finding a way to bring it up? If you do, I suggest talking about EQ’s benefits, such as EQ improving one’s career, enhancing leadership skills and improving relationships – all of which increases our sense of purpose and gives us a fuller life. You can also point out that EQ is a huge part of being a top performer, but that to learn EQ, they must first want to learn it. Daniel Bobinski, M.Ed. is a certified behavioral analyst, a best-selling author and a popular speaker at conferences and retreats. He loves working with teams and individuals to help them achieve workplace excellence. Reach Daniel through his website, www.MyWorkplaceExcellence.com, or (208) 375-7606.

JUNE 2019 | OR TODAY |

OUT OF THE OR nutrition

Sugar Alcohols; Benefits of Drinking Water with Meals and Snacks By Nicole Wavra, M.P.H., R.D. & Kristen N. Smith, Ph.D., R.D.N.

Q: What are sugar alcohols and how are they used? A: Sugar alcohols occur naturally in some fruits and vegetables and are also a man-made ingredient commonly used as a substitute for sugar in foods. Despite their name they do not contain ethanol, found in alcoholic beverages. Their chemical structure looks similar to the chemical structure of both sugar and alcohol, hence the name. There are a number of different sugar alcohols used in products like gum, jelly spreads, beverages, candy and toothpaste. If you read nutrition labels you will most often find the sugar alcohols xylitol, erythritol, sorbitol or maltitol listed in the ingredients. Sugar alcohols contain fewer calories than sugar and are only partially digested so they have less of an effect on blood sugars. Sugar alcohols can help prevent tooth decay and they exert benefits on the gut. In addition, sugar alcohols in food also add texture, moisture and prevent browning when heated.

62 | OR TODAY | JUNE 2019

If consumed in large amounts, sugar alcohols may contribute to gas, bloating and diarrhea. Just like sugar alcohols differ in their calories and taste, they also differ in how much GI distress they cause. – Nicole Wavra, M.P.H., R.D.

Q: Should I drink water during meals? A: There has been some confusion about the importance of drinking water with meals and snacks. In fact, there have even been some concerns regarding water intake and negative impacts on digestion. However, Michael F. Picco, a physician from the Mayo Clinic notes “There’s no concern that water will dilute digestive juices or interfere with digestion. In fact, drinking water during or after a meal actually aids digestion.” Regular and adequate water intake is essential for good health. Especially important is to consume enough water (and other beverages) to ensure that your body is able to effectively

absorb and use the nutrients in the food you eat. An added bonus? Water acts as a natural stool softener and helps to prevent and/or lessen constipation. Drinking a glass of water around meal time can also help take the edge off of hunger and may assist in weight management. It’s always important to consider your own personal situation – if you have been advised by a physician to limit water or fluids at any point throughout the day, heed that advice. If you want to increase water intake, be sure to bring it up at your next medical appointment. – Kristen N. Smith, Ph.D., R.D.N.

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Rachel’s Very Beginner Cream Biscuits INGREDIENTS: • 2 1/4 cups commercial or homemade self-rising flour, divided • 1 1/4 cups heavy cream, divided • Butter, softened or melted, for pan and finishing

the

64 | OR TODAY | JUNE 2019

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

Two-ingredient Biscuits: Just Right for Tasty Meals s a California girl, I knew nothing about making biscuits. I never learned how in my bread baking classes at the Le Cordon Bleu either. Scones, yes. Biscuits, not so much. So imagine how thrilled I was to have a personal class with my Southern belle buddy Cynthia Graubart. The co-author of “Southern Biscuits” (Gibbs Smith, $24.99) shipped me a special flour, and when she arrived for a visit we rolled up our sleeves and made biscuits. Tender, crisp on the outside, fluffy on the inside, heavenly biscuits. I couldn’t believe how easy it was once you get the hang of it. Not only is it a fun activity to do with a friend, but it is also seriously simple. While these directions look long and complicated, they are in fact a guide to foolproof biscuit-making. Graubart named this particular dish after her daughter Rachel because she could make them at a young age. How can biscuits only contain two ingredients? As Graubart explains it, the flour is self-rising and the fat is

OUT OF THE OR recipe

in the cream so there’s no need for any other ingredients. I do hope you will try these biscuits when you are in the mood for this Southern signature bread. I think they would make a lovely addition to any brunch with butter and jam, or alongside the main course in place of bread. If you feel like you need even more help, check out Graubart’s biscuit-making on YouTube. Biscuit tips • Fork-sift means using a fork to sift the flour right in the bag to lighten it. • Use a shallow wide bowl to mix the dough. • The dough should be sticky and slightly wet. • Push the dough together without overhandling. • Use a plastic flexible mat to turn over the dough. • You can make these ahead and gently reheat, if desired. • Never turn the biscuit cutter; push down and then release the biscuit; otherwise, the biscuit won’t rise properly.

Rachel’s Very Beginner Cream Biscuits Makes 12 to 14 (1/2-inch thick) biscuits 1.

Preheat oven to 450 F. Select the baking pan by determining if a soft or crisp exterior is desired. For a soft exterior, use an 8- or 9-inch cake pan, a pizza pan or an ovenproof skillet where the biscuits will nestle together snugly, creating the soft exterior while baking. For a crisp exterior, select a baking sheet or other baking pan where the biscuits can be placed wider apart, allowing air to circulate and create a crisper exterior. Butter the pan. Fork-sift or whisk 2 cups of the flour in a large bowl, preferably wider than it is deep, and set aside the remaining 1/4 cup. Make a deep hollow in the center of the flour by pressing with the back of your hand. Slowly but steadily stir 1 cup of cream, reserving 1/4 cup cream, into the hollow with a rubber spatula or large metal spoon, using broad circular strokes to quickly pull the flour into the cream. Mix just until the dry ingredients are moistened and the sticky dough begins to pull away from the sides of the bowl. If there is some flour remaining on the bottom and sides of the bowl, stir in just enough of the reserved cream to incorporate the remaining flour into the shaggy, wettish dough. If the dough is too wet, use more flour when shaping. Lightly sprinkle a flexible plastic cutting board, wooden board or other clean surface with some of the reserved flour. Turn the lumpy, wettish dough out onto the board and sprinkle the top of the dough lightly with flour if sticky. With floured hands, fold the dough in half and pat it into a 1/3- to 1/2-inch-thick round, using a little additional flour only if needed. (If using the flexible plastic sheet, fold the sheet over itself to fold the dough.) Flour again, if sticky, and fold the dough in half a second time. If the dough is still clumpy, pat and fold a third time. Pat dough into a 1/2-inch-thick round for normal biscuits, a 3/4-inch-thick round for tall biscuits, or a 1-inch-thick round for giant biscuits. Brush off any visible flour from the top. For each biscuit, dip the biscuit cutter into the reserved flour and cut out the biscuits, starting at the outside edge and cutting very close together, being careful not to twist the cutter. The scraps may be combined to make additional biscuits, although they will be tougher. Using a metal spatula if necessary, move the biscuits to the pan or baking sheet. Bake the biscuits on the top rack of the oven until light golden brown, about a total of 10 to 14 minutes. After 6 minutes of baking, rotate the pan in the oven so that the front of the pan is now turned to the back, and check to see if the bottoms are browning too quickly. If so, slide another baking pan underneath to add insulation and retard the browning. Continue baking another 4 to 8 minutes, until the biscuits are light golden brown. When they are done, remove from the oven and lightly brush the tops with softened or melted butter. Turn the biscuits out upside down on a plate to cool slightly. Serve hot, right side up.

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Makayla Holmberg, Sterile Processing Technician, Surgery Reedsburg, WI

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The 10 Best Foods to Reduce Anxiety

he foods you put on your plate really can make a real difference when it comes to mental health issues, including anxiety disorders – the top cause of mental illnesses in the United States. How does food help with anxiety? Anxiety is caused in part by an imbalance of neurotransmitters, explains Ali Miller, R.D., an integrative dietitian and author of “The Anti-Anxiety Diet.” Neurotransmitters are chemical messengers believed to play a role in mood regulation. A diet that features nutrients from whole-food ingredients helps create neurotransmitter balance by improving the gut microbiome. When it comes to dialing down anxiety, what you don’t eat is just as important as what you do, says Nathalie Rhone, R.D.N., a New York City-based nutritionist and founder of Nutrition by Nathalie. “Foods that are processed, high in sugar and refined carbohydrates, fried or loaded with additives can all heighten anxiety since they are inflammatory in your system, which can eventually affect your brain,” she said. Here, 10 foods to add to your meal-prep routine now.

1. Turkey

We’ve all been warned that tryptophan, an amino acid in turkey, can send us into a food coma after a big Thanksgiving meal. But tryptophan’s relaxation effect can also ease anxiety.

2. Salmon

8. Avocado

Avocados are packed with monounsaturated fats and antioxidants that help optimize circulation, which contributes to better blood flow to the brain. The fruits also supply 20 different vitamins and minerals, including key nutrients tied to mood, like folate, B6 and potassium.

This versatile and satiating fish is loaded with omega-3 9. Oats fatty acids, which are essential for brain health and a wellLike leafy greens, oats contain high levels of soothing minerfunctioning nervous system. Opt for wild salmon over farmed als like magnesium. Just 1/2 cup of dry oats provides a third varieties. of the recommended daily target for magnesium.

3. Dark chocolate

10. Chamomile tea

4. Asparagus

– Health.com

The antioxidants in dark chocolate trigger the walls of blood vessels to relax, which boosts circulation and lowers blood pressure. Go ahead, make a small chunk of 70 percent (or higher) dark chocolate your new 3 p.m. pick-me-up. One possible reason for asparagus’s soothing effect: high levels of the B vitamin folate, a shortage of which has been linked to depression. Just 1 cup of cooked asparagus provides nearly 70 percent of the daily recommended intake of folate.

According to a report from Harvard Medical School, chamomile tea has been shown to be an effective alternative treatment for anxiety. Cozy up with a cup before bed to calm your system and set yourself up for a better night’s sleep.

5. Sauerkraut

Fermented products such as sauerkraut are considered probiotic foods, and consuming more of them on a regular basis appears to have a mood-boosting effect.

6. Citrus fruits

“Our adrenal glands are the most concentrated storage tissue for vitamin C and they use the nutrient in the regulation of cortisol,” says Miller. That might explain why studies show that vitamin C supplementation has been linked to reduced anxiety levels. Add lemons or limes to your tea and brighten yogurt bowls or salads with oranges and grapefruit.

7. Broccoli

Dark green veggies like broccoli contain magnesium, “a calming mineral that can help with relaxation, as well as with keeping things moving through your digestive system,” notes Rhone. Other top sources of magnesium include almonds, sunflower seeds and sesame seeds.

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JUNE 2019 | OR TODAY |

OUT OF THE OR scrapbook

AORN SCRAPBOOK ore than 5,700 perioperative nurses and health care professionals gathered in Nashville, Tennessee, at the 66th annual AORN Global Surgical Conference & Expo. Attendees could choose from over 100 educational sessions representing nine educational tracks Global, Ambulatory, Clinical, Educator, Infection Control/Infection Prevention, Sterile Process, Leadership/Management, Evidence-based Practice/Research, Quality/Quality Indicators. Also, attendees can watch recordings of the sessions they missed through AORNâ&#x20AC;&#x2122;s on-demand streaming service to continue their education after returning home from the conference. Among total attendees, 800 emerging leaders and experienced executives participated in the sold-out Leadership Summit, a four-day mini conference within AORN Expo focused on the management and business side of perioperative nursing. Speakers provided updates from the Joint Commission, megatrends impacting the U.S. health care industry and a certificate program on surgical services financial management. The trade show portion of the conference boasted a full expo hall with 467 exhibitors displaying their latest surgical products, technologies and services. New in 2019, AORN presented the OR of the Future, supported by Getinge. Another first at the 2019 event was AORNâ&#x20AC;&#x2122;s Reverse Trade Show. OR Today also hosted a rooftop party, sponsored by BD, at Rock Bottom Brewery with entertainment by Carl Wockner. The event was designed to offer additional networking opportunities and treat readers to live music in the Music City!

68 | OR TODAY | JUNE 2019

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INDEX

advertisers

Alphabetical Action Products, Inc.……………………………………… 58

Calzuro.com……………………………………………………… 25

Microsystems……………………………………………………… 5

Advance Medical Designs, Inc.………………………… 4

Cygnus Medical…………………………………………………… 9

Molnlycke Health Care…………………………………… 53

AIV Inc.…………………………………………………………………13

Healthmark Industries Company, Inc.………… 10

oneSOURCE Document Site………………………… 49

ALCO Sales & Service Co.……………………………… 57

Heartland Medical Sales Service………………………17

OR Today Webinar Series……………………………… 39

Arthroplastics, Inc.…………………………………………… 29

Innovative Medical Products………………………… 72

Pure Processing……………………………………………………71

ASCA………………………………………………………………… 57

MD Technologies inc.……………………………………… 63

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

Avante Patient Monitoring……………………………… 30

Medline………………………………………………………… 22-23

TBJ Incorporated……………………………………………… 32

BD……………………………………………………………………… 27

MedWrench……………………………………………………… 38

TIDI………………………………………………………………… 20-21

C Change Surgical……………………………………………… 6

MFW Consultants To Professionals……………… 48

TRU-D……………………………………………………………………19

ANESTHESIA

HOSPITAL BEDS/PARTS

PRESSURE ULCER MANAGEMENT

Heartland Medical Sales Service………………………17

ALCO Sales & Service Co.……………………………… 57

ASSET MANAGEMENT

INFECTION CONTROL

Action Products, Inc.……………………………………… 58 Molnlycke Health Care…………………………………… 53

Microsystems……………………………………………………… 5

Advance Medical Designs, Inc.………………………… 4 ALCO Sales & Service Co.……………………………… 57 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.………… 10 Medline………………………………………………………… 22-23 Pure Processing……………………………………………………71 Ruhof Corporation…………………………………………… 2,3 TBJ Incorporated……………………………………………… 32 TIDI………………………………………………………………… 20-21 TRU-D……………………………………………………………………19

categorical

ASSOCIATION ASCA………………………………………………………………… 57

CARDIAC PRODUCTS C Change Surgical……………………………………………… 6

CARTS/CABINETS ALCO Sales & Service Co.……………………………… 57 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.………… 10 TBJ Incorporated……………………………………………… 32

INSTRUMENT STORAGE/TRANSPORT

REPAIR SERVICES Avante Patient Monitoring……………………………… 30 Cygnus Medical…………………………………………………… 9 Heartland Medical Sales Service………………………17

REPROCESSING STATIONS Pure Processing……………………………………………………71 TBJ Incorporated……………………………………………… 32

SAFETY Calzuro.com……………………………………………………… 25 Healthmark Industries Company, Inc.………… 10

CONSULTING

Cygnus Medical…………………………………………………… 9

SINKS

MFW Consultants To Professionals……………… 48

INSTRUMENT TRACKING

CS/SPD

Microsystems……………………………………………………… 5

Pure Processing……………………………………………………71 TBJ Incorporated……………………………………………… 32

MD Technologies inc.……………………………………… 63 Microsystems……………………………………………………… 5

MONITORS

DISINFECTION

ONLINE RESOURCE

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

MedWrench……………………………………………………… 38 oneSOURCE Document Site………………………… 49 OR Today Webinar Series……………………………… 39

DISPOSABLES

Avante Patient Monitoring……………………………… 30

ALCO Sales & Service Co.……………………………… 57

OR TABLES/BOOMS/ACCESSORIES

ENDOSCOPY

Action Products, Inc.……………………………………… 58 Innovative Medical Products………………………… 72

Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.………… 10 MD Technologies inc.……………………………………… 63 Ruhof Corporation…………………………………………… 2,3

OTHER AIV Inc.…………………………………………………………………13 TRU-D……………………………………………………………………19

ERGONOMIC SOLUTIONS

PATIENT MONITORING

Pure Processing……………………………………………………71 ALCO Sales & Service Co.……………………………… 57

AIV Inc.…………………………………………………………………13 Avante Patient Monitoring……………………………… 30 Heartland Medical Sales Service………………………17

FLUID CONTROL

POSITIONING PRODUCTS

FALL PREVENTION

Arthroplastics, Inc.…………………………………………… 29

FOOTWEAR Calzuro.com……………………………………………………… 25

GENERAL AIV Inc.…………………………………………………………………13

70 | OR TODAY | JUNE 2019

Action Products, Inc.……………………………………… 58 Advance Medical Designs, Inc.………………………… 4 Cygnus Medical…………………………………………………… 9 Innovative Medical Products………………………… 72 Molnlycke Health Care…………………………………… 53

SKIN PREPARATION BD……………………………………………………………………… 27

STERILIZATION Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.………… 10 TBJ Incorporated……………………………………………… 32

SURGICAL Heartland Medical Sales Service………………………17 MD Technologies inc.……………………………………… 63

SURGICAL INSTRUMENT/ACCESSORIES C Change Surgical……………………………………………… 6 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.………… 10

TELEMETRY AIV Inc.…………………………………………………………………13 Avante Patient Monitoring……………………………… 30

TEMPERATURE MANAGEMENT C Change Surgical……………………………………………… 6

WASTE MANAGEMENT Advance Medical Designs, Inc.………………………… 4 Arthroplastics, Inc.…………………………………………… 29 MD Technologies inc.……………………………………… 63 TBJ Incorporated……………………………………………… 32

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