OR Today - October 2019

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PRODUCT FOCUS SURGICAL EQUIPMENT

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CE ARTICLE ACINETOBACTER BAUMANNII

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OUT OF THE OR INTERMITTENT FASTING & EXERCISE

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CORPORATE PROFILE

OCTOBER 2019

PAGE 50

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contents features

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STERILE ENVIRONMENT BEST PRACTICES Sterilization is one of the most critically important aspects of patient safety today. This underlines the vital role played by sterile processing in today’s health care environment.

These personnel are responsible for providing clean, functioning and sterilized disinfected instruments.

They also must perform quality control monitoring of equipment and processes involved in reprocessing instrumentation.

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Perioperative nurses and SPD

The goal of this continuing education

CORPORATE PROFILE: HEALTHMARK

professionals from across the country

program is to inform nurses about

Healthmark Industries is celebrating its 50th

gathered at the Palms Casino Resort

Acinetobacter baumannii, a potentially

anniversary. Over the years, the company has

in Las Vegas, Nevada for the 2019 OR

untreatable hospital-acquired pathogen that

experienced a great deal of growth with a

Today Live Conference. Attendees

is becoming more common.

variety of products and services. Known for

OR TODAY LIVE RECAP

CE ARTICLE

44

were able to network in the exhibit hall,

providing innovative solutions for infection

exchange ideas during educational

control to health care facilities, they are currently

sessions and earn CE credits.

expanding their product line.

OR Today (Vol. 19, Issue #10) October 2019 is published monthly by MD Publishing, 1051 Tyrone Rd., Bldg. 100, Ste. 120, Tyrone, GA 30290. POSTMASTER: Send address changes to OR Today at 1051 Tyrone Rd., Bldg. 100, Ste. 120, Tyrone, GA 30290.

For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. Š 2019

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OCTOBER 2019 | OR TODAY |

7

contents features

PUBLISHER John M. Krieg

john@mdpublishing.com

VICE PRESIDENT Kristin Leavoy

kristin@mdpublishing.com

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EDITOR John Wallace

SPOTLIGHT ON

editor@mdpublishing.com

Laura Cornelis, MSN, APRN, FNP-BC

ART DEPARTMENT Jonathan Riley Karlee Gower Amanda Purser

ACCOUNT EXECUTIVES Jayme McKelvey Megan Cabot

DIGITAL SERVICES

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win lunch for your department!

Spiced Sweet Potato Chocolate Bundt Cake

OR TODAY CONTEST

RECIPE OF THE MONTH

INDUSTRY INSIGHTS

11 News & Notes 18 O R Today Live Recap 22 I AHCSMM: TJC Releases Safety Alert on Ophthalmology Devices; FDA Modifies Medical Device Reporting Process 24 CCI: Continuous Professional Development in Perioperative Nursing 26 Webinar Series Reaches New Highs

Cindy Galindo Kennedy Krieg Erin Register

CIRCULATION Lisa Cover Melissa Brand

WEBINARS Linda Hasluem

ACCOUNTING Diane Costea

IN THE OR

29 Market Analysis: Reports Predict Growth Among Surgical Markets 30 Product Focus: Instrument Storage & Transport 34 CE Article: Acinetobacter baumannii: Winning the Battle Against Antibiotics

OUT OF THE OR

56 Spotlight On 61 Fitness 62 Health 65 EQ Factor 66 Nutrition 68 Recipe 70 Pinboard 72 OR Today Live Scrapbook

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INDUSTRY INSIGHTS

news & notes

Spacelabs Unveils Dual-Mode Patient Monitor Spacelabs Healthcare announced the release of its DM4 dual-mode monitor, the newest member of the company’s patient monitoring line. The DM4 combines the simple performance of a spot-check monitor with the sophistication of continuous monitoring and is designed to provide caregivers with a versatile solution for accurately and efficiently monitoring basic vital signs on adult, pediatric and neonate patients.

The DM4 is designed for use in any patient care environment where basic vital signs monitoring is needed, and

it is expected to enable caregivers to adapt to changes in patient condition without having to locate additional equipment. In spot-check mode, the DM4 can wirelessly transmit individual patient records to an electronic medical record system (EMR), or it can be used to efficiently collect and download multiple patients’ records in batch mode from a central location. If more vigilance is required, the DM4 can be quickly switched to continuous monitoring mode with alarm notification support. •

Bon Secours Mercy Health Saves $2M Via Standardization Summit The first ever Medline-hosted Standardization Summit for recently combined Bon Secours Mercy Health drove $2.1 million in immediate savings for the organization, the system and Medline announced. The in-person workshop was designed to bring together otherwise disparate regional and clinical expertise to dramatically condense product sampling and discussion. Additionally, the event delivered immediate changes and outcomes through this unique collaboration.

“We put these groups together to look at policies and protocols so we can fine tune them,” says Amy Whitaker, RN, BSN, and vice president of supply chain clinical integration, Bon Secours Mercy Health. “By taking the best of the best between the two groups, the outcome is far superior to what we’ve had independently which only further strengthens our desire to improve care and outcomes.”

Teams consisted of experts spanning clinical, infection prevention and supply chain – many of whom never had met in person despite working together for years via conference calls. The groups drove the following: • Tackled standardization across 12 product categories • 44 percent SKU reduction • Lowered number of manufacturers from 250 to 48

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“Standardization is vital for direct patient caregivers because we want to do the same thing every time we do a particular task or procedure. That provides reliability for the patient and improves our patient outcomes overall,” says Anne Macy, system director for infection prevention, Bon Secours Mercy Health.

Attendees also approved three clinical solutions programs for the entire system. Skin Health Solutions empowers frontline staff to consistently deliver evidence-based best practices for skin and wound care. Additionally, teams are already working side-by-side to gather baseline information to design ways to fight two of the most common healthcare-associated infections: catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs).

“This collaboration truly elevates what it means to be an integrated partner,” says Kyle Hoffman, market director, Medline. “Seeing these unique discussions unfold was incredibly gratifying for everyone around the table. Teams are quite eager to build upon these supply chain decisions and dig into how reducing practice variation through intuitive design and evidence based practice can improve patient outcomes.” •

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INDUSTRY INSIGHTS

news & notes

AAAHC Awards Advanced Orthopaedic Certification The Accreditation Association for Ambulatory Health Care (AAAHC) recently awarded the Minnesota Valley Surgery Center (Burnsville, MN) with the first AAAHC Advanced Orthopaedic Certification – since its official launch in October 2018 – focusing on total joint replacements. The certification is designed for ambulatory surgery centers (ASCs) that provide a high quality of care and comply with rigorous, specialty-focused standards.

“We perform a variety of orthopaedic procedures and our patients know they can turn to us for expert medical care,” said Total Joint Medical Director Robert Hartman, M.D. of the Minnesota Valley Surgery Center. “Building upon our ongoing compliance to AAAHC Accreditation requirements, our Advanced Orthopaedic Certification emphasizes our commitment to continually improving our orthopaedic processes and performance.”

To achieve Advanced Orthopaedic Certification, the Minnesota Valley Surgery Center underwent a rigorous onsite survey. Surveyors evaluated the ASC’s approach to the continuum of care for total joint replacement patients, beginning with the pre-admission consultation and education, surgery, discharge follow-up, and rehabilitation.

The center demonstrated use of evidence-based clinical practice guidelines, ongoing performance improvement strategies, and an effective organizational infrastructure aimed at providing safe and effective care.

This three-year certification program was designed by an expert panel of practicing professionals in orthopaedic and spine procedures. AAAHC-Accredited organizations wanting to achieve this certification may choose from two types of advanced certification, total joint or complex spine. Centers can also pursue a combined certification that addresses both specialties.

Also, the AAAHC is seeking enthusiastic health care professionals to volunteer for its new committees, called Governance Units. Supporting AAAHC’s 1095 Strong, quality every day philosophy, the Governance Units will facilitate the improvement and growth of the association, advocate for patient safety, share innovative ideas and provide guidance and strategy on educational opportunities. • For details or to apply, visit AAAHC.org.

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8 NueHealth Surgery Centers Achieve ACE Designation Eight NueHealth ambulatory surgery centers have been awarded the Ambulatory Center of Excellence (ACE)™ designation by ValueHealth. ACE designation not only aligns with the guidelines of national accrediting bodies, but adds stricter clinical, quality and financial measures.

When achieved, these facilities are able to transition to advanced payment models, including prospective bundles with warranty. This ACE designation recognizes the delivery of high-quality care, consistent clinical outcomes, and high patient satisfaction while reducing the overall cost of surgical care.

The following NueHealth facilities have achieved this honor: • City Place Surgery Center – Creve Coeur, Missouri • The Surgical Center at Columbia Orthopaedic Group – Columbia, Missouri • Gold Coast Surgicenter – Chicago, Illinois • St. Joseph Center for Outpatient Surgery – St. Joseph, Missouri • Viewmont Surgery Center – Hickory, North Carolina • Jefferson Surgical Center at the Navy Yard – Philadelphia, Pennsylvania • The Center for Minimally Invasive Surgery – Munster, Indiana • Riddle Surgical Center – Media, Pennsylvania Status as an ACE designated facility means these eight facilities have met nationally recognized standards for the delivery of quality health care set by ValueHealth management principles. Not all ambulatory health care organizations seek accreditation; not all that undergo the rigorous survey process are granted accreditation. ACE begins with facility-level designation and may be supplemented by procedurespecific certifications for joint replacements, certain spine procedures, other complex orthopedic procedures as well as other surgical specialties.

Ambulatory surgery centers seeking ACE designation undergo an extensive self-assessment and survey

by ValueHealth experts. The survey is consultative and educational, presenting best practices to help an organization improve its care, cost and patient satisfaction. • For more information, visit www.nuehealth.com or visit www.valuehealth.com.

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INDUSTRY INSIGHTS

news & notes

Unity Hospital Offers Radiation-Free Neurosurgery Platform Unity Hospital, part of Rochester Regional Health, is the first hospital in New York State to offer the 7D Surgical System for spine and cranial procedures. Now, surgeons at Unity are assisted by a fast and radiation-free tool that provides real-time 3D images using machine-vision, camera-based technology.

Equipped with technology similar to self-driving cars, the 7D Surgical System has been referred to as a “GPS for the spine and brain.” It is the first and only Machine-Vision Image Guided Surgery (MvIGS) platform. For the first time, spine surgeons can guide their tools to the critical anatomy using sophisticated camera

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technology linked to a computer in the operating theater. Unlike time-consuming conventional image-guided surgery (IGS) systems that depend on intraoperative radiation, this new MvIGS platform can achieve an incredibly fast surgical workflow for spine and cranial procedures, reducing operative time for patients.

Dr. Paul Maurer, chief of neurosurgery at Unity, has a different term. “It’s like having a wingman,” he describes.

“This enhances the confidence, safety and efficiency of a skilled surgeon. Just like technology for a skilled pilot, you have to have the training and the ability, but this tool makes the work safer than ever.” •

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INDUSTRY INSIGHTS

news & notes

OR Today Webinar Series Celebrates Anniversary OR Today magazine launched the OR Today Webinar Series in 2014 with a goal to provide additional continuing education opportunities to readers. The webinar series joined the monthly continuing education article as an avenue to earn CE credits. The following year, the inaugural OR Today Live Surgical Conference became another option for those seeking CE credits.

The OR Today Webinar Series has experienced tremendous success and growth.

“The OR Today Webinar Series is now in its sixth year and has grown from 3 when it started in 2014 to 18 this year. It has established itself as a popular educational resource for OR professionals. In 2020, we will see an increase in the number of webinars offered per month to two or three webinars, which is a great opportunity to gain even more continuing education credits,” OR Today Webinar Marketing Manager Linda Hasluem said.

“The webinars are particularly successful because they provide the opportunity to gain a continuing education credit for viewing the webinar and they are free! Having great sponsors, whether large or smaller companies, and providing relevant and up-to-date subjects is also a great asset to the continuing success of the webinars,” she added. “The webinars are creating a valuable library of relevant subjects and being able to view them on our website is a huge plus, as many of the OR professionals are not always able to attend the live webinars.”

In 2014, the OR Today Webinar Series kicked off in the fall with three webinars during the fourth quarter of the calendar year. The number of

14 | OR TODAY | OCTOBER 2019

sessions tripled the following year and the series continues to grow.

There are 18 webinars on the schedule this year and attendance records have been broken weekly. In 2015, the first full year of the webinar series, 680 individuals attended 12 sessions for an average of 57 attendees per webinar.

In comparison, the 2019 campaign has almost doubled those attendance numbers after only nine webinars.

This year, 1,194 people have attended live webinars. Average attendance for each session has ballooned from 57 in 2015 to 132 in 2019. This does not include all of the health care professionals who are viewing recorded webinars in our online archives.

Healthmark sponsored a recent record-breaking OR Today webinar.

Healthmark Marketing Manager Matt Smith says the company sees the webinars as an excellent way to join in supporting perioperative professionals.

“We have partnered with OR Today for many years now, their magazine has always done a great job of educating readers about new guidelines, techniques and equipment as other relevant news in the industry,” Smith said. “Sponsoring the webinar is another great vehicle to provide compelling information to health care professionals.”

“It’s an opportunity for OR and SPD professionals to get a chance to see our education staff talk about relevant issues that hospitals face on a daily basis,” he added. “They speak around the country and at major conferences, but not everyone gets a chance to attend and experience a workshop or a speaking engagement.

This gives our audience more access to being able to see them.”

Smith is not surprised by the growth of the webinar series because of the valuable information it provides health care professionals.

“We are honored to be able to partner with OR Today and that more professionals are finding the information useful and signing up to attend. We look forward to more opportunities in the future to share more content that professionals will find interesting and helpful that will provide solutions to ongoing daily challenges,” he said.

Healthmark is not alone in finding value through webinar sponsorships. BD, Medline, Microsystems, RepScrubs, oneSource, Ruhof and 3M Health Care are among a who’s who of health care companies sponsoring webinars in 2019.

Hasluem sees even more growth in coming years based on the attendees’ reactions to each session.

“The positive feedback we always receive after the webinars really enforces how important they have become to the OR community,” she said.

Hasluem added that one testimonial sums up the impact the webinars have on the OR professionals.

“OR Today’s webinars are very insightful. They educate you on issues being faced in countless hospitals around the world. They give you ideas on how to face these issues head on, how to create a culture of change, and make a difference. I’m glad I tuned in,” A. Hetzel, RN, infection preventionist, shared after one webinar. • For more information about the OR Today Webinar Series, visit ORToday.com/Webinars.

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Court Dismisses Lawsuits Against Patient Warming System 3M has announced that a federal court dismissed all of the federal lawsuits against the 3M Bair Hugger system.

The announcement comes after six years of defending the company’s patient warming system.

The decision dismisses more than 5,000 lawsuits filed by plaintiffs’ attorneys, who claimed that the warming system was responsible for infections suffered by patients during surgery. Those lawsuits were consolidated in a multidistrict litigation in federal court in Minnesota.

The federal decision in favor of 3M comes six months after the Minnesota Court of Appeals upheld a Minnesota state court order dismissing 61 similar cases filed by lawyers on behalf of Minnesota plaintiffs.

“There is no legitimate scientific support for the plaintiffs’ theory. We are pleased that the court has dismissed all of the cases in the multidistrict litigation,” said Dr. Todd Fruchterman, general manager, 3M Medical Solutions Business. “Most importantly, we want physicians and patients to understand that the practice of patient warming is supported by leading health care institutions, professional societies and the U.S. Food and Drug Administration. Our industry-leading 3M Bair Hugger system has been proven to be a safe, effective and efficient method of delivering patient warming therapy.”

In its order, the federal court granted 3M’s request to exclude the plaintiffs’ general causation experts, leaving the plaintiffs with no scientific support for their claims.

The court previously had agreed to allow the plaintiffs’ experts to testify in court. After those experts testified in the first Bair Hugger system trial in 2018 and after the publication of a new study on surgical site infections, 3M asked the court to revisit its earlier decision.

3M argued that the new evidence further proved that the plaintiffs’ experts lacked scientific support for their claims. On July 31, 2019, the court granted 3M’s motion.

The company says the plaintiffs’ infection theory was invented by 3M competitor Augustine Temperature Management and its founder Scott Augustine.

This court decision does not dismiss two similar cases filed in state courts in Missouri and Texas.

In August 2017, the U.S. Food and Drug Administration sent a letter to health care providers stating that it continues to recommend the use of patient warming devices, including forced-air warming devices, for surgical procedures when clinically warranted. •

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INDUSTRY INSIGHTS

news & notes

Key Surgical Introduces Enzymatic Solutions Key Surgical LLC, a leading global provider of sterile processing, operating room, and endoscopy supplies, announces the addition of an enzymatic detergent and a pre-cleaning solution from Dr. Weigert.

Key Surgical is the only distributor to introduce Dr. Weigert products to hospitals in the United States: neodisher MultiZym, a detergent for manual cleaning, and neodisher PreStop, a spray foam used for pre-cleaning in the operating room. MultiZym and PreStop have been used in CSSDs throughout Europe with proven success delivering effective, efficient cleaning results.

Dr. Weigert MultiZym is a multi-enzymatic detergent that delivers cleaning results through a combination of three classes of enzyme: protease, lipase, amylase. MultiZym is specifically formulated for use in manual cleaning in sinks, immersion baths and ultrasonics and features simple dosing. This pH neutral, low-foaming detergent is formulated to be safer for personnel and the environment while

16 | OR TODAY | OCTOBER 2019

still delivering maximum results as it’s free of boric acid, borates, perfume/scent and dye making it a user-friendly solution in the CSSD. Material compatibility includes surgical stainless steel, optics, standard synthetic materials, anodized aluminum, silicone and materials used in anesthetic equipment. MultiZym is available as a 1.32 gal (5 L) bottle.

Dr. Weigert PreStop is a pre-cleaning product designed to apply to instruments after use in the operating room and before further reprocessing can occur. PreStop is an easyto-use spray foam and helps prevent the growth of microorganisms, corrosion, and potentially irreparable damage on instrumentation. It also prevents the drying of surgical residues by keeping the instruments wet. Instruments treated with PreStop can be stored for up to 72 hours before reprocessing. Each bottle of PreStop is 25.4 fl oz (.75 L) and is packaged 12/case. • For more information, visit www.keysurgical.com.

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INDUSTRY INSIGHTS

news & notes

Pure Processing to Recognize Sterile Processing MVPs For the fifth consecutive year, Pure Processing will recognize sterile processing MVPs with its annual CS Week Pin & Photo Program.

The most valuable sterile processing “players” aren’t playing at all. They’re fighting to defend patients and win against increasingly dangerous pathogens. They must score a penalty-free touchdown for each reprocessed device and do it without player injuries.

Pure Processing recognizes all sterile processing teams as MVPs, that are pushing hard to reach the end zone every day. In its fifth year, Pure Processing’s pin and photo program allows CS departments to promote teamwork and show everyone their game faces. Participants can visit www.pure-processing.com/csweek to request pins for their department.

To participate in the giveaway contest, departments must follow Pure Processing and post a picture wearing the pins with the hashtag #CSWeekMVPs on LinkedIn, Facebook or Instagram.

“Our CS Week pin and photo program is our way of recognizing the immeasurable contributions of central sterile professionals. Not only does it bring awareness to often overlooked staff of CS departments, but we have found that it is one of the most fun and rewarding events of the year,” shared Marketing Coordinator Stacie Ast-Kutzbach.

“We hope that one day we will feature every incredible sterile processing department in our CS Week photo sub-

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mission video.”

Founded in 2010, Pure Processing LLC develops and manufactures ergonomic solutions for easy, fast, safe and effective medical device reprocessing. The company helps surgical, diagnostic, endoscopy and reprocessing departments protect their most important assets: their staff and their medical device inventory.

By applying a thorough understanding of regulatory guidance, ergonomics and the instrument cleaning environment, Pure Processing helps providers achieve productive, consistent, compliant and comfortable pre-cleaning processes that support optimal clinical outcomes for their patients.

A technician’s job requires hours of standing at a sink, conducting many repetitive movements every hour and every day. This work carries a risk for injury, from neck and shoulder strain, to wrist conditions, to chronic back and leg pain.

Pure Processing provides numerous practical solutions to eliminate or greatly reduce the injury risk in all these workspaces, and to help make pre-cleaning workflow compliant with regulations and highly productive.

Pure Processing’s portfolio of products continues to grow as new opportunities are discovered to help precleaning technicians optimize their tasks, streamline their workflow and contribute to patient safety.

For more information, visit pure-processing.com.

OCTOBER 2019 | OR TODAY |

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INDUSTRY INSIGHTS

news & notes

SURGICAL CONFERENCE

Viva Las OR Today Live!

By ERIN REGISTER erioperative nurses and SPD professionals from across the country recently gathered at the Palms Casino Resort in Las Vegas, Nevada for the 2019 OR Today Live Conference. Attendees were able to network in the exhibit hall, exchange ideas during educational sessions and earn CE credits. The classes, super sessions and keynote included world-class speakers and provided attendees with invaluable knowledge to take back to their departments.

Everyone even had some fun with Elvis and the Rat Pack!

P

The conference kicked off on Sunday, August 18, with registration and a CNOR® Prep Course presented by the Competency and Credentialing Institute (CCI). Education continued into the afternoon with CE super sessions. The speakers gave phenomenal presentations and received a lot of positive feedback from attendees.

Phyllis Quinlan’s presentation “Understanding and Effectively Managing Bullying & Incivility in Your Perioperative Department” was described by an attendee as “excellent, motivating and encouraging.” Sharon McNamara, William Duffy and Jamie Ridout also gave a very impressive super session titled “Leadership Across Generations.”

One attendee said, “Sharon McNamara is an awesome leader and speaker!

This has been a creative and insightful presentation.”

Sunday concluded with a welcome reception in the exhibit hall sponsored

18 | OR TODAY | OCTOBER 2019

by USOC Medical. Attendees were able to enjoy complimentary food and drinks while networking and engaging with exhibitors from all over the United States.

Attendees continued to build connections and relationships at an after party sponsored by Las Vegas HEALS Attendees were not the only ones to provide positive feedback from the conference. AIV Vice President of Sales and Business Development, Jeff Taltavull, was asked what keeps AIV coming back to exhibit at the conference every year.

He answered, “AIV keeps coming back because OR Today Live has been a great show for us. It helps us to establish relationships, and the intimacy of the show helps us build those relationships.”

Phyllis Quinlan with MFW Consultants also provided a review on her conference experience.

“The first thing is the company (OR Today Live) itself. They are just really true professionals who are very easy to work with and very easy to navigate,

as well as very supportive. They make participation for someone like myself, a speaker, very easy and user-friendly. Also, the participants are absolutely wonderful,” Quinlan said. “These are wonderful professionals who have come with a commitment to lifelong learning. They ask very valuable questions and are very engaged in the presentation. They are just a joy to be around.” Quinlan added that OR Today Live is “professional, authentic and timely.”

Following a complimentary breakfast Monday morning, attendees were energized and ready for the second day of OR Today Live. Education continued with several seminars on a wide variety of topics. Charles Hughes presented on table top sterilizers, and an attendee noted, “Chuck is wonderful about relating the lessons to real life scenarios. Learning this stuff was fun!” Additionally, Jim Stobinski’s presentation on the twin threats to nursing knowledge was said to be “very valuable information for aspiring leaders.”

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After the morning seminars, lunch was served in the exhibit hall, where a special guest made an appearance. Elvis Presley came to see what OR Today Live had to offer! He mingled with attendees and exhibitors and everyone was able to get their picture taken with him. Attendees also had the option of participating in a scavenger hunt to win great door prizes and OR Today merchandise. Educational sessions continued throughout the afternoon.

When asked about his thoughts on the classes, University of Minnesota Medical Center’s John Zender stated, “I really enjoy the more intimate class size and the content of those classes. It has been excellent and very valuable. It is almost like you’re one-on-one. There has been a lot of interaction, and I really like it.”

Attendees ended the day at the Party Under the Stars sponsored by AIV. The party was held in the Moon lounge on the 55th floor of the Palms and included dinner, an open bar featuring a special ORTini, an appearance by The Rat Pack and a spectacular view of the city.

Attendees danced and sang while Dean Martin, Frank Sinatra and Sammy Davis Jr. serenaded the audience.

The conference concluded on Tuesday with more educational seminars followed by a fantastic keynote luncheon and address by Rafael J. Grossman, MD, FACS. Grossman’s speech was titled “Spatial Computing, AR and VR: A Revolution in Health Care, Education and Beyond.”

After the conference, one attendee stated, “This was my second time coming to this conference. Another good experience. I will come again! I also brought another nurse director who has never come to this conference, and she thanked me for letting her know about this conference. She plans to come again as well.

The sessions were all informative and the evening dinner entertainment was very much appreciated. I liked the scavenger hunt with the exhibitors and the prizes.

I really liked the low-cost of the registration and appreciate your efforts on bringing the cost down!”

President and CEO of MD Publishing, the publishing company of OR Today, John Krieg also had a few words to say about OR Today Live.

“OR Today Live Las Vegas far exceeded our expectations and really turned the corner in terms of attendance, quality education and vendor engage-

ment,” Krieg stated. “The response from the OR leaders at the show was just tremendous. They are raving over the intimate yet productive environment, the level of professionalism and overall quality of the program. We will continue to work hard and build on the success of this year’s event and make 2020 even more spectacular!”

MD Publishing Vice President Kristin Leavoy also summed up the conference by saying it “exceeded all expectations.”

“From the incredible lineup of presenters for our educational sessions to the generosity and support of our vendors and sponsors, our team could not be more pleased with the results. The 50% increase in this year’s attendance speaks for itself,” Leavoy said. “Word is spreading, OR Today Live is the conference to attend!”

Indeed, OR Today Live is the conference to attend for perioperative nurses and SPD professionals looking for continuing education, new ideas, networking opportunities and more.

For more information about OR Today Live, visit ORTodayLive.com.

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INDUSTRY INSIGHTS

IAHCSMM

TJC Releases Safety Alert on Ophthalmology Devices; FDA Modifies Medical Device Reporting Process

By Susan Klacik, BS, CRCST, CIS, CHL, ACE, FCS n May 2019, The Joint Commission (TJC) issued a Quick Safety alert for tonometers and other devices that touch the eye. A tonometer is a device used to determine the intraocular pressure, the fluid pressure inside the eye; this device touches the eye and must be disinfected between uses, along with other medical devices that touch the eye.

I

At a minimum, items that touch the eye must undergo high-level disinfection and items that contact sterile tissue must be sterilized. The American Academy of Ophthalmology reports that due to a failure to properly disinfect this equipment there have been transmissions of adenovirus and herpes simplex virus, hepatitis C virus, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and prions such as Creutzfeldt-Jakob disease.

TJC surveys have identified the following shortcomings of the disinfection process of ophthalmology devices in health care facilities, which have resulted in declarations of immediate threat to health and safety of patients: • Lack of awareness with manufacturers’ instructions for use (IFU); • Misinterpretation of manufacturers’ IFU; • Lack of staff training; and • Lack of leadership oversight.

The quick safety alert also provided the following safety actions for health care facilities to take to prevent an infection associated with tonometers and other ophthalmology devices:

22 | OR TODAY | OCTOBER 2019

• Review eye instrumentation IFU to ensure the devices are being reprocessed appropriately.

• Ensure disinfectants are listed as compatible and are FDA-approved as high-level disinfectants. Some products, such as bleach, may be listed for pre-cleaning. If bleach is listed as an option to use, note that it is a disinfectant that does not require clearance through the FDA. • Follow manufacturers’ IFU for both the devices used for ophthalmology examinations and procedures, as well as cleaning and disinfection products.

• There should be an individual knowledgeable about the different types of disinfectants and who reviews the product label and instructions for use.

• If instructions are unclear, contact the item’s manufacturer (and the manufacturer of any products used for reprocessing) for clarification.

FDA modifies medical device reporting process The U.S. Food and Drug Administra-

tion (FDA) is taking steps to improve its ability to identify and address medical device safety signals and provide patients and health care professionals with important information that can be used to make better-informed health care decisions. This is being accomplished by updating the FDA’s Medical Device Reporting (MDR) Program, which monitors device performance, detects potential devicerelated safety concerns or signals, and contributes to the benefit-risk assessment of medical devices.

In June, the FDA announced it would be formally ending its Alternative Summary Reporting (ASR) Program. Under this program, manufacturers of some medical devices could request an exemption from the requirement to file individual medical device reports for certain events that were well-known and had well-established risks associated with a particular device and instead submit quarterly summary reports of such events. According to a June 21, 2019, statement from the director of the FDA’s Center for Devices and Radiological Health,

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the FDA granted 108 such exemptions to individual manufacturers for certain well-known events associated with specific devices, which were often already described in the product labeling available to health care professionals and patients. The ASR Program allowed the FDA to more efficiently review reports of well-known, wellunderstood adverse events, so it could focus on identifying and taking action on new safety signals and less understood risks.

Beginning in 2017, the FDA took steps to formally sunset the ASR Program and to streamline medical device reporting by implementing the Voluntary Malfunction Summary Reporting (VMSR) Program. The VMSR Program allows the FDA to efficiently detect potential safety signals and free up resources to better address the highest risks, such as deaths and serious injuries, associated with medical devices. As the name suggests, this is a voluntary program that allows manufacturers to report certain device malfunctions in a summary form on a quarterly basis, rather than on an individual basis, for eligible device types. Reports from this voluntary program are publicly available in the Manufacturer and User Facility Device Experience (MAUDE) database. The MAUDE database maintains reports submitted by both mandatory reporters (manufacturers, importers and device user facilities) as well as by voluntary reporters such as health care professionals, patients and consumers. There are exceptions, however; reports of a death or serious injury are not allowed to be submitted via the VMSR Program and the FDA may still require individual malfunction reports instead of summary report for devices that are eligible for the program, such as when individual reports are necessary to address a public health issue.

The MAUDE reporting system will also undergo a change to make it more user friendly over the next few years as part of a broader effort to modernize the medical device program’s information technology systems. The objective of these improvements is to make MDR data more usable and

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easier to find. This effort is intended to increase transparency in medical device reporting.

Medical device reports submitted to the FDA are only one source used to monitor medical devices in use; however, there are some limitations to these reports. The FDA has identified that some submissions are incomplete, inaccurate, untimely and duplicative, and some include unverified or biased data. The modernized, active surveillance will use real-world data and is a primary focus for the FDA. In response to these issues and in an effort to improve reporting, the FDA has been developing a new program called the National Evaluation System for health Technology (NEST) to systematically use real-world data to rapidly identify and help address safety signals once devices are in use through active surveillance. Active medical device surveillance will better protect patients by, for example, continuously using analytical software algorithms to evaluate large data sets on device performance and patient safety associated with device use in routine clinical practice.

An important part of this new surveillance system is the establishment of the unique device identification (UDI) system. The UDI requires medical devices are marked on their labels with a unique code that can be used to identify the device through its distribution and use in patients. Device identifiers are stored in a public database; currently, there are more than two million device records, and patients and health care professionals can download information about their devices. The FDA also has engaged in international efforts to facilitate a harmonized approach to adoption of UDI systems worldwide.

– Susan Klacik, BS, CRCST, CIS, CHL, ACE, FCS, is an IAHCSMM Clinical Educator.

A modified version of this article was published in the Sept/Oct 2019 issue of PROCESS, a publication of the International Association of Healthcare Central Service Material Management.

“OR Today’s webinar’s presentations are timely, and spot on to the important topics facing today’s OR managers and directors.“ G. Harmon, Director of Perioperative Nursing Services

WEBINAR SERIES

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OCTOBER 2019 | OR TODAY |

23

INDUSTRY INSIGHTS CCI

Continuous Professional Development in Perioperative Nursing

By James X. Stobinski, Ph.D., RN, CNOR, CSSM (e) randon Bennett, in a recent editorial in this publication, raised the issue of the orientation of nurse managers and leaders entering the OR. I agree with Bennett’s thoughts regarding perioperative nurse leaders, but I would like to extend that perspective and consider the continuum of a career to include the education and training processes for all nurses in perioperative nursing. I believe it is time to question long held assumptions here also.

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We have long assumed that some amount of classroom teaching combined with a lengthy precepted learning experience is enough to establish competency for the complex specialty of perioperative nursing. How a nurse attains a level of competency can be explained in the tenets of Patricia Benner’s “Novice to Expert Theory of Skill Acquisition” (Stobinski, 2008). This initial orientation and pre-licensure education are a necessary foundational component for perioperative nursing competency. All of us completed a pre-licensure educational course, passed the NCLEX exam and then eventually entered the field of perioperative nursing. But … a degree, especially a degree taken decades ago, cannot meet continuing professional development (CPD) needs over the course of a career.

Although operating room nursing was among the first recognized nursing specialties, and has existed for over a century, little has changed in our methods

24 | OR TODAY | OCTOBER 2019

for bringing nurses into the profession.

The issue of how to maintain competency in practice is a prominent concern for nursing but especially so in perioperative nursing. The building blocks of competency in any nursing specialty include pre-licensure education and the subspecialty education upon entry to the OR, but there is one more essential ingredient – ongoing education and training throughout a career. This is the Continuous Professional Development (CPD) which keeps us current and safe in our practice.

The rapid pace of change demands the attention of our specialty and the fresh look which Bennett spoke to previously. This rapidity of change also demands that we have meaningful CPD over the entire course of our career.

The need for lifelong learning was also advanced by Missi Merlino, the current president of the board of directors for AORN, in her recent column in the AORN Journal (2019). As the CEO of the Competency and Credentialing Institute, which administers the CNOR credential, I concur with Merlino on this need. I believe that certification and the attendant ongoing professional development activities can address the issue of maintenance of competency.

Nurses holding credentials administered by CCI have access to our Learning Management System (LMS), a rich repository of learning activities which have been vetted by certified perioperative nurses to be relevant to current practice.

In addition, we have assembled these activities based in part on recommenda-

James X. Stobinski, Ph.D., RN, CNOR, CSSM (e)

tions from the Institute of Medicine (US) Committee on Planning a Continuing Health Professional Education (2010).

The report published by this select group stressed the need to move beyond a reliance on CE activities to more meaningful methods such as self-assessment, individualized learning plans and reflective learning. These methods have a solid basis in the evidence-based literature and have the potential to facilitate lifelong learning and enhance competency levels.

These concepts are incorporated within the CCI system which is available without additional charge to nurses holding CCI certifications.

The resources available in the CCI LMS are possible, in part, because of the generous support of our partners. CCI will expand this repository over time and is committed to keeping it current.

Please stay current with CCI through our various social media channels as we will soon announce new partnerships WWW.ORTODAY.COM

and initiatives to meet the ongoing professional development needs of the perioperative nursing community.

– James X Stobinski, Ph.D., RN, CNOR, CSSM (E), if the CEO of the Competency and Credentialing Institute. He may be contacted at 720-257-4372 or jstobinski@cc-institiute.org.

References 1. Institute of Medicine (US) Committee on Planning a Continuing Health Professional Education Institute (2010). Redesigning Continuing Education in the Health Professions. Washington (DC): National Academies Press. Available from: https://www.ncbi.nlm.nih.gov/ books/NBK219811/ doi: 10.17226/12704.

2. Merlino, M. (2019). Creating Our Future Through Lifelong Learning. AORN Journal (100)1, pp. 2-4.

3. Stobinski, J.X. (2008) Perioperative nursing competency. AORN Journal (88)3. pp. 417-436.

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INDUSTRY INSIGHTS

WEBINAR SERIES

news & notes webinars

Webinar Series Reaches New Highs

By John Wallace R Today webinars continue to break attendance records. The past two webinars, sponsored

by Healthmark and Medline, set new highs for attendance.

“ Truly enjoyed the webinar – evidence

The August 15 webinar “Preventing Surgical Site Infections Through a Decolonization Bundle” was presented by Rosie D. Lyles, MD, MHA, MSc, and sponsored by Medline. It set new records with the most registrations and attendees since the series began in 2014!

A week later, those records were broken with 563 people registered for the Healthmark-sponsored webinar “C.H.I.P Tips: Care, Handling, Inspection & Prevention for the Sterile Processing Professionals” presented by Cheron Rojo and Seth Hendee. The session drew 278 attendees for the live presentation on August 22. Attendees gave the webinar a rating of 4.1 on a 5-point scale.

During her OR Today webinar presentation, Lyles discussed the continuous battle of emerging pathogens. She addressed how to prevent the spread of Staphylococcus aureus (staph), the leading pathogen that causes healthcare-associated infections (HAIs) in U.S. health care facilities? Staph is a common bacteria that can cause serious and costly infections, like surgical site infections, and patients are at higher risk for a staph infection when they have surgery. Current recommendations by health care organizations have led to a reduction in methicillin-resistant Staphylococcus aureus (MRSA) in health care, but progress has slowed. In the webinar, Lyles explored the benefits of evidence-based decolonization bundles and their critical role in preventing staph infections for patients having surgery.

The presentation received positive reviews in a post-webinar survey.

“It was very interesting to be able to compare what the webinar discussed versus what we are beginning at our own institution and the success of this implementation,” shared T. Shutt, a RN project coordinator.

“This was an excellent overview of literature to support our practice to reduce SSIs in our surgical patients. There were two elements of practice that we do not have in our SSI bundle that I will be sharing with our teams. One of the studies discussed the patient risk factors of being either a diabetic, smoker, obese, uses ETOH along with cases that are 140min in length or longer have an increased risk of infection if they

decrease SSIs was highly evidence-

O

26 | OR TODAY | OCTOBER 2019

supporting the importance of skin cleansing and proactive measures to based from peer-reviewed studies.”

R. Scott, Clinical Educator possess three or more of these risk factors. The second strategy we need to implement is the CHG bath 2-5 days before surgery,” said S. Bressoud, RN. “This was an excellent presentation. Our facility is currently working on an orthopedic and colon surgical site prevention bundle and as an ICP this will assist me in making recommendations for decolonization. Thank you,” said S. LaPisto, RN ICP. “This webinar is very timely as our facility is battling a few SSIs. We have just started nose to toes and it’s great to see some study data,” Infection Preventionist A. Guina said.

“This was my first time attending an OR today webinar and I found the information not only relevant, but critical in the prevention of SSIs. I am a nurse by training. I also currently practice as a pre-surgical nurse on a PRN basis in addition to my IP job. It will enhance my knowledge to educate my patients about the risks of SSI and what can be done to prevent it. I will be sure to refer to the evidence presented during the webinar when I am providing education to my patients to ensure their compliance is key in attaining a good surgical outcome,” Infection Preventionist D. Gelaw said.

“Awesome webinar! I loved the research study data showing efficacy, as well as framing past decolonization techniques with new current methods. Really great presenter, easy to understand, hear, perfect delivery pace,” Clinical Director Infection Control C. Anderegg said.

Cheron Rojo, AA, CRCST, CIS, CER, CFER, CHL, and Seth Hendee, CRCST, CIS, CHL, CER, CFER, IAHCSMMapproved instructor, Clinical Education Coordinators at Healthmark Industries reviewed sterile processing tips in everyday tasks. They also reinforced the basic technical principles that are used in the sterile processing department.

They went on to discuss the importance of handling instrumentation and equipment within your department, as well as

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INDUSTRY INSIGHTS

newswebinars & notes understanding the impact that standards and guidelines have in a properly functioning department that processes instrumentation and medical devices.

Attendees had great things to say about the webinar.

“Excellent review of quality checks and balances in the SPD department and monies needed to provide quality review by this staff for the OR staff and ultimately our patients,” Surgery QA Coordinator J. Jesse said.

“The webinar was very thorough and covered topics that were very important and sometimes overlooked or not practiced routinely enough in the workplace. It refreshed and reinforced the practice standards, thereby improving efficiency, quality and patient outcomes,” Central Sterile Tech A. O’Brien said.

“I am brand new to my position, and this webinar gave me a great overview of what should be checked for quality assurance as well as how. I will be reviewing our procedures to see what we need to change,” RME Coordinator D. Maestas said.

“The ‘C.H.I.P. Tips: Care, Handling, Inspection & Prevention for Sterile Processing Professionals’ webinar is an extremely educating and informative webinar. Our SPS enjoyed watching and learning new information and validate processes that we currently have. Thank you so much,” SPS Educator L. Hall said.

“The webinar provided insights that not all professionals always think about. For example, testing the monopolar/bipolar cords or the insulated forceps, not a lot of techs are aware that these are crucial things to be tested. Also, testing of the washer temperature for the washers is also something that is crucial. Attending webinars like these are great for new staff and also techs that have been doing this for years; it’s a great learning experience and a great refresher. Mahalo for the great information,” Manager J. Martinez said.

For more information about the OR Today webinar series, including recordings of previous webinars and registration for upcoming sessions, visit ORToday.com and click on the “Webinars” tab.

For more information about the OR Today Webinar Series, including recorded presentations and information about upcoming sessions, visit ORToday.com and click on the Webinar tab.

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IN THE OR

market analysis

Reports Predict Growth Among Surgical Markets Staff report he global surgical equipment market is expected to reach $16.9 billion by 2024, according to a report from ResearchAndMarkets.com. The report states that the market is expected to see a 7.3% compound annual growth rate (CAGR) during the forecast period.

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Road accidents are expected to be a major factor influencing market growth. According to the Association for Safe International Road Travel, nearly 2.35 million people are injured every year in road accidents. The introduction of electrosurgical instruments has contributed to the growth of the surgical instruments market, which is expected to drive the market during the forecast period, according to the report. Additionally, a growing trend for minimally invasive surgeries, such as electrosurgery, will add to market growth. Wound injury management is also commonly conducted with surgical sutures in cases of accidents. Thus, the demand for surgical equipment is expected to grow during the forecast period.

Grand View Research also reports continued growth.

The global surgical instruments/ equipment market is anticipated to reach a value of $20.3 billion by 2025, according to a report by Grand View Research Inc. The firm also suggests that an increasing number of minimal-

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ly invasive surgeries across the globe should accelerate market growth.

“Treatment of chronic diseases often require surgeries. Rising prevalence of chronic diseases, such as, cardiovascular and neurological disorders is adversely impacting the society. Surgery is considered as the primary mode of treatment for patients suffering from such diseases, thereby, giving rise to more number of surgical procedures being conducted. Minimally invasive surgeries are also highly adopted by surgeons for treating several heart disorders,” according to Grand View Research.

The report also states that electrosurgical equipment is anticipated to witness attractive growth over the forecast period due to an increase in minimally invasive surgeries. Plastic and reconstructive surgeries are expected to show lucrative CAGR in the coming years.

Asia Pacific is expected to show the fastest growth over the forecast period owing to the rising number of road accident cases in India.

The forecasted growth of the global surgical equipment market should also boost the growth of the surgical instrument transport and storage market.

Acumen Research and Consulting recently announced a research study on the surgical instrument tracking systems market.

The establishment of a distinctive scheme of object identification (UDI) through the Food and Drug Admin-

istration (FDA), is one of the key variables driving the development of operative instrument tracking systems, according to Acumen.

“The surgical device tracking systems have several advantages. It was used earlier only in the management of the instrument count sheet and in certain fundamental tools traceability. The use of tracking systems has, however, become more extensive with the introduction of technology. The introduction of 2D barcodes has allowed sterile processor employees to identify tools more correctly and also assist to develop a solid history of the use of each tool,” the report states. “The data enables the employees to determine if the tool requires repair. The identification of the radio frequency (RFID) in medical facilities enables to define and monitor the device. The use of RFID tags and operational follow-up solutions can automatically monitor critical devices in health care organizations and guarantee that the right, suitable instruments for each operation are accessible.”

Under key findings, the report states that an increased acceptance of surgical instrument tracking systems for stock management and their capacity to improve patient security, will contribute to market growth.

The projected growth of this market is another indicator that the surgical instrument storage and transport market should receive a boost in coming years.

OCTOBER 2019 | OR TODAY |

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IN THE OR

product focus

Healthmark Industries

Transportation Identification Tag Designed for compliance with OSHA standard CFR 1910.1030, the Transportation Identification Tag is 3.125 inches by 5.125 inches with one perforated tab, a green top tab with “CLEAN” in black text, a fluorescent orange/red bottom tab with “DIRTY” in black text and the removable OSHA approved “Biohazard Label” adhesive backing. The Transportation Identification Tag is produced for transporting materials considered a biohazard, while acting as a communication tool in the process by labeling a cart or container “biohazard” upon its return to the sterile processing department, the label assists in supplying information to the OR/Procedure Room. • For more information, visit www.hmark.com

Medline

Gemini Bonded Wrap Gemini Bonded Wrap was intentionally designed to make holes more visible to ensure patient safety, the dual color bonded blue/ pink helps differentiate specific instrument sets, and the basket weave pattern yields better surface adhesion for indicator tape while still remaining soft so it is easy to drape. Gemini bonded wrap is versatile for use in all major sterilization cycles. The strong, dual-layer, 100% polypropylene construction provides high-level barrier protection against fluid and particulates – providing greater confidence in the sterilization process. • For more information, visit www.medline.com

30 | OR TODAY | OCTOBER 2019

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IN THE OR

product focus

Key Surgical

Scope Baskets Key Surgical Scope Baskets are the perfect containment device to use in the sterilization process of rigid scopes. Constructed of durable stainless steel, the baskets feature fixed silicon brackets that help hold a rigid scope in place during sterilization and transportation. A fully removable lid allows for easy placement of the scope in the basket. The lid slides into place on the basket and locks with an easy-to-use locking mechanism. It is available in various sizes.

It is Key Surgical’s largest basket and includes a small mesh basket to hold scope accessories. It is compatible with steam, EtO, and gas plasma sterilization. •

Summit Medical

For more information, visit www.keysurgical.com.

InstruSafe XL Transport Container Transporting da Vinci SP, Xi scopes and EndoWrist instruments appropriately and effectively is a difficult task. Use the InstruSafe XL Transport Container to get the job done right. This durable container is the perfect size, enabling professionals to soak and protect instruments while they travel from the OR to sterile processing. •

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OCTOBER 2019 | OR TODAY |

31

IN THE OR

product focus

Cygnus Medical

Oasis Scope Transport Tray The Oasis Scope Transport Tray is the first single-use tray that eliminates the need to manually disinfect trays between uses. It significantly improves infection control, while reducing labor costs. Now available in a size perfect for small diameter scopes. • For more information, visit www.cygnusmedical.com.

32 | OR TODAY | OCTOBER 2019

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IN THE OR

continuing education

Acinetobacter baumannii: Winning the Battle Against Antibiotics

BY BETH R. WALLACE, MPH, CIC

he patient was well on his way to recovery from head trauma after a fall from a motorcycle. However, in the hospital, he developed a fever, stiff neck, and severe headache.

He became confused and nonresponsive. Tests of his cerebral spinal fluid disclosed low glucose and elevated protein levels and an increased neutrophil count. A strain of Acinetobacter baumannii, which is resistant to all antibiotics, was isolated from his CSF. The patient was treated unsuccessfully with meropenem (Merrem) and systemic polymyxin E (colistin). He died two months later, not from his injury but from a preventable hospital-acquired A. baumannii infection, which was untreatable with available antibiotics.

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Antibiotics have changed the world, dramatically reducing human mortality from infectious diseases. Between 1936 (the year before sulfonamides were available) and the early 1950s (15 years into the antibiotic era), deaths in the U.S. from infectious diseases fell 75%, from about 280 per 100,000 to 60 per 100,000. Antibiotics brought about such a massive decline in infectious disease deaths that all medical advances since the early 1950s — in-

34 | OR TODAY | OCTOBER 2019

cluding critical care medicine — have resulted in only minor reductions in deaths from infections. In the next 50 years, infectious disease deaths were reduced only an additional 20 per 100,000.1 However, deaths from infectious diseases are no longer declining. Infectious diseases are the fourth leading cause of death in the United States, third in developed nations overall, and the second leading cause of death worldwide.2 We are now seeing the emergence of increasing numbers of resistant pathogens threatening the effectiveness of antibiotics, and the death rate from serious infectious diseases is climbing. Untreatable infections that were of concern in the pre-antibiotic era are once again becoming a pervasive problem for U.S. healthcare facilities. Bacterial resistance has increased to such an extent that there are a growing number of hospital-acquired infections for which there are no adequate therapeutic options. The Centers for Disease Control and Prevention estimates that more than 2 million people are infected each year with antibiotic-resistant pathogens, and these infections result in the deaths of at least 23,000 people annually in the U.S.2,3 Numbers in Europe are similar with approximately 25,000 deaths attributed to antibiotic-resistant bacteria each year.2

Relias LLC guarantees this educational program free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity.

See Page 41 to learn how to earn CE credit for this module.

Goal and objectives The goal of this continuing education program is to inform nurses about Acinetobacter baumannii, a potentially untreatable hospital-acquired pathogen that is becoming more common. After studying the information presented here, you will be able to: • List the two main features that make A. baumannii a dangerous pathogen • Identify the risk factors for infections with A. baumannii • Determine the steps needed to control A. baumannii transmission in hospitals

The emergence of A. baumannii strains resistant to all commercially available antibiotics is an example of the growing threat of antimicrobial

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IN THE OR

continuing education resistance. A. baumannii had earned the nicknamed “Iraqibacter” because it is the gram-negative pathogen most frequently isolated from war wounds, with a tendency to infect previously healthy wounded veterans transported to military hospitals from Iraq and Afghanistan.4 Research has shown that A. baumannii — once thought to originate in the soil in Iraq and Afghanistan — is a hospital pathogen mainly acquired in the EDs, ORs, and ICUs of combat support hospitals.

The pathogen has been found in every hospital on the aeromedical evacuation route for combat-wounded soldiers in Iraq, Germany, and the U.S.5,6 In wounded soldiers, A. baumannii can cause devastating prostheses infections, deep wound infections, serious skin and soft-tissue infections, necrotizing fasciitis, catheter-related sepsis, primary bloodstream infections, urinary tract infections, meningitis, endocarditis, intra-abdominal abscess, and pneumonias. A number of injured soldiers infected with Acinetobacter have carried the pathogen back home to the U.S., where it has spread throughout the healthcare system, putting civilian patients and hospital workers at risk.6 Although wounded military personnel have been the traditional point of entry for Acinetobacter into U.S. hospitals, evidence exists that the epidemiology of Acinetobacter in general and multidrug-resistant Acinetobacter (MDR-AB) in particular has changed.

Increasing prevalence of Acinetobacter has been identified in many U.S. healthcare facilities, especially longterm care facilities (LTCF).

A study in California compared A. baumannii isolates from patients in a hospital and residents of a nearby subacute care long-term care facility. Although the majority (66%) of the hospital isolates were found to be multidrug resistant, 100% of the LTCF isolates were MDR. Molecular analysis and epidemiologic investigation

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suggest that there was transmission among residents of the LTCF, but also transmission from at least one resident to patients at the hospital during an overlapping stay.

Infection prevention and antimicrobial stewardship resources are often more limited in subacute care settings, and cases such as this study suggest the need for acute care facilities to work cooperatively with subacute facilities.7 LTCF residents are likely at very high risk for MDR-AB acquisition due to multiple hospitalizations and many courses of antibiotic therapy. Risk factors inherent to the residents are also part of the issue, including an elderly population with multiple comorbidities and the possibility of immune system compromise.8 A. baumannii is a gram-negative (or gram-variable), nonspore-forming, nonmotile, aerobic coccobacilli bacteria commonly found in healthcare environments.9,10 There are many different species of Acinetobacter, but A. baumannii is the most common species to cause clinical illness. Many strains of Acinetobacter are found in the environment in areas where there is moisture — damp soil, wetlands, etc.

These strains often harbor the same intrinsic resistance found in clinically relevant strains, and these ubiquitous environmental species can transfer modes of resistance to clinically relevant organisms.10 Most hospital-acquired A. baumannii isolates represent pathogens whose antibiotic resistance cannot be blamed on the community use of antibiotics or the use of antibiotics in animals, but rather on failures of hospital hygiene — direct transmission from patient to patient through environmental surfaces and healthcare provider hands — as well as the overuse of antibiotics in hospitals.3 Reports of A. baumannii infection in critically ill patients began in the 1960s.10,11 In the 1970s, A. baumannii infections were easily treated because

the pathogen was susceptible to most antibiotics. Although recognized as a pathogen, it was not of much concern because of this treatability. However, even in 1975, an outbreak of Acinetobacter was noted, and the causative agent was found to have diminished susceptibility to antibiotics.11 As a result of increased use of broad-spectrum antibiotics in hospitals during the past several decades, the incidence of multidrug-resistant, extensively drug-resistant (XDR), and pandrug-resistant (PDR) strains of A. baumannii (strains resistant to all antibiotics) began increasing worldwide.

By the end of the 1970s, resistance was reported to sulfonamides, beta-lactams, and aminoglycosides. By the late 1990s, carbapenems (imipenem [Primaxin] and meropenem [Merrem]) were the only remaining antimicrobial agents that could be used for severe infections.

MDR-AB is an isolate resistant to at least three of the four classes of antimicrobial agents: penicillins, cephalosporins, fluoroquinolones, and aminoglycosides. XDR Acinetobacter is resistant to the antimicrobial agents listed above, plus carbapenems. PDR Acinetobacter is resistant to all commercially available antimicrobial agents: penicillins, cephalosporins, fluoroquinolones, aminoglycosides, carbapenems, polymyxins, colistin, and tigecycline (Tygacil).10

The Jump in Resistance A significant jump in Acinetobacter infections resistant to carbapenems (from less than 5% to more than 40%) in U.S. hospitals occurred in just 10 years.10,12 Carbapenems had been the only option for most Acinetobacter isolates since the late 1990s.13 Without carbapenems, only colistin (a drug abandoned in the 1960s because of kidney damage and neurotoxicity) or tigecycline (Tygacil) are available as last-resort antimicrobials for XDR

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continuing education Acinetobacter infections. However, resistance to both colistin and tigecycline is increasing.10,12 Of 28 XDR Acinetobacter isolates identified from patients receiving wound therapy, 50% were found to be resistant to colistin.

Genetic analysis determined that all 14 of the colistin-resistant specimens were related.13 This sizable increase in resistance has been occurring for several reasons, including Acinetobacter’s innate drug resistance, its remarkable ability to rapidly acquire additional resistance genes, and its ability to survive under a wide range of environmental conditions in hospitals for extended periods of time.6,10,11

Fending Off Antibiotics A. baumannii has a wide range of intrinsic and acquired resistance mechanisms that are active against antibiotics. Like other gram-negative bacteria, Acinetobacter has a double cell membrane with a unique lipopolysaccharide (composed of a lipid and a carbohydrate) outer membrane, a periplasmic space (space between the inner and outer cell membranes), and an inner cell wall. Resistance features on the outer membrane include porins, protein channels that regulate permeability. Although the outer cell membrane and the presence of porins are common to gram-negative bacteria, Acinetobacter seems to have an edge against antibiotics because its cell wall has fewer porins than most, and those that are present are very small.

In the presence of antibiotics, some Acinetobacter isolates suppress porin production even further. Efflux pumps are also present in the cell wall, which pump the antibiotics out of the cell, keeping the level from becoming toxic.

The organism also has beta-lactamases (enzymes) that neutralize the effectiveness of beta-lactam antibiotics that get into the periplasmic space.

Genetic analysis of Acinetobacter has identified a large section of its genetic

36 | OR TODAY | OCTOBER 2019

sequence that confers intrinsic resistance. This “island” consists of 45 genes.

Together, the efflux pumps, porins, and beta-lactamases are powerful intrinsic mechanisms for antibiotic resistance.

Other resistance mechanisms include penicillin-binding protein modifications, antimicrobial-inactivating enzymes, and mutations that change targets (binding sites) or cellular functions.5,10 Acinetobacter are also able to acquire iron, adhere to epithelial cells, and form biofilms on surfaces (equipment and medical devices) and on human epithelial cells. Biofilms are colonies of bacteria encased within a self-produced, sticky matrix of extracellular polysaccharides that form whenever enough moisture exists.

These biofilms facilitate exchange of resistance genes and mechanisms and protect the bacteria from the body’s immune defenses, antimicrobial agents, and disinfectants.5,10,14 It is likely that Acinetobacter’s outer membrane protein A (OmpA) plays an important role in antibiotic resistance through adhesion to host cells and other Acinetobacter cells in a biofilm, and resistance to the complement system.

Disrupting the genetic code responsible for OmpA in a mouse model led to reduced mortality.10 Many of these resistance mechanisms have come from genetic mutations or from other species of bacteria through the acquisition of genetic materials carrying resistance genes. Nearly all of the resistance genes Acinetobacter has acquired are from Salmonella, Pseudomonas, and E. coli.5 Most Acinetobacter infections occur in critically ill hospitalized patients with severe underlying diseases who have an extended exposure to an ICU.5,9,11 Infections usually involve organ systems with a high fluid content (e.g., the respiratory tract, blood, CSF, peritoneal fluid, and the urinary tract) and are often due to multidrug-

resistant strains.15 Risk factors include underlying diseases, such as chronic lung disease or diabetes; prior treatment with broad-spectrum antibiotics, especially carbapenems and thirdgeneration cephalosporins; surgery and surgical drains; mechanical ventilation; indwelling central IV catheters; urinary catheters; monitoring devices; prolonged length of stay; and poor infection control practices.6,10,14,15 According to the most recent complete report available from the Centers for Disease Control and Prevention, A. baumannii was the 14th most common pathogen isolated in U.S. hospitals and was responsible for 2.1% of hospitalacquired bloodstream infections, 0.9% of urinary tract infections, and 6.6% of pneumonias.16 Although new data are not available for all of these measures, A. baumannii now accounts for a full 7% of hospital-acquired pneumonias.3 Especially among patients in the ICU, Acinetobacter is a common cause of a hospital-acquired, aggressive, and often fatal pneumonia (with a mortality rate of 40% to 60%). It ranks fifth (behind Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella, and Enterobacter spp.) as a major cause of ventilator-associated pneumonia. In its most severe form, the pneumonia is characterized by a fulminant clinical course and a secondary bloodstream infection. In the early stages of infection, Acinetobacter can trigger a severe systemic inflammatory response that can include disseminated intravascular coagulation, septic shock, and adult respiratory distress syndrome.5,15-17 In U.S. hospitals, Acinetobacter is the 13th most common cause of catheterrelated bloodstream infections, with mortality rates that range from 30% to 75%.18 Risk factors include prior antibiotic use, intravascular catheters, mechanical ventilation, and colonization at other body sites. Prognosis is determined by the patient’s underlying condition.5,15,18 In addition to pneu-

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continuing education monias and bloodstream infections, Acinetobacter can cause meningitis after head trauma or neurosurgical procedures, urinary tract infections in patients with indwelling catheters, and wound infections.5,10

Treatment A. baumannii is difficult to eradicate; only a few antimicrobial agents are effective. Carbapenems are the drug of choice for MDR-AB infection, even though carbapenem-resistant isolates are being increasingly reported worldwide. With XDR Acinetobacter infections, colistin remains the treatment of choice, although no consensus has been reached on the best treatment for carbapenem-resistant organisms.5,10 Tigecycline has been used for resistant Acinetobacter, but serum concentrations can be low, and clinical trials have shown tigecycline to be inferior to alternatives.10 One of the most important aspects of treating Acinetobacter infections is timely initiation of treatment, regardless of the agent.10,18 Combination therapy may be more effective than single agents, and many studies show results with colistin plus an additional agent. These studies are limited by being in vitro for the most part.18 In light of apprehension surrounding availability of new antibiotics, a new approach to payment to drug companies for antimicrobial development may be helpful.2 In the current state, antibiotic development has a very low return on investment for pharmaceutical companies, and many have eliminated their antibiotic development programs. A proposed change to the current model that may entice more antibiotic development is the Priority Antimicrobial Value and Entry award. The PAVE award would provide public funding for the first years of an antibiotic being on the market, with the costs transitioning on a value rather than volume basis to insurance

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providers in later years. Programs such as this proposal are being evaluated worldwide, and they’re encouraged by the World Health Organization and other international entities.19 While there are concerns about a lack of new antibiotics in the development pipeline, several new antibiotics are at various stages of testing, and show promising results against Acinetobacter with new mechanisms of activity.18 In addition to these antibiotics in development, there are many other treatment options being evaluated for efficacy against Acinetobacter.

These include the use of vaccines, bacteriophages, and phototherapy, among others.10 Given Acinetobacter’s propensity to develop resistance to antibiotics, other therapies may be especially beneficial.

In the Hospital Acinetobacter is not only difficult to eradicate from infected patients, but also from the environment. It has been shown to persist, and remain viable, on solid surfaces in healthcare environments for months or even years.10 A. baumannii can survive up to five months on inanimate surfaces and equipment through a wide range of temperature, pH, humidity, and nutrient availability.15 Numerous outbreaks have been linked to environmental contamination with the pathogen. Bed spaces and rooms occupied by affected patients have been demonstrated to be contaminated by the patient and by healthcare workers’ hands. Contaminated surfaces serve as reservoirs of infection; healthcare workers touch the contaminated surface and then transmit the pathogen. Even though rooms are cleaned between patients, a patient has a higher risk of Acinetobacter acquisition if the previous patient in the room was infected or colonized with the pathogen. There are many reports of outbreaks of Acinetobacter where collected environmental cultures grew

the same strain as the outbreak strain.20 Airborne dissemination of Acinetobacter also is possible, although direct contact is the most important mode of transmission. After educational campaigns targeting hand hygiene, sterilization and disinfection, and other infection prevention measures, a teaching hospital noted that Acinetobacter transmission was ongoing despite decreases in other infections. The hospital used two ICUs to prospectively study Acinetobacter transmission and the possible role that the air plays. One hundred eighty-six air samples were collected, and nearly 14% were positive.

Not surprisingly, higher concentrations of Acinetobacter were found in the air near infected patients than in air collected from other areas.

One strain isolated from the air was detected in air cultures over 27 days and was found to be genetically related to the causative agent of one patient’s infection. Another air specimen was genetically identical to two patient infections, one 20 days after the air sample and one 102 days later. The authors suggest further studies are necessary to truly understand the role of air in Acinetobacter transmission.21 Surface contamination and then transmission on healthcare worker hands or via contaminated equipment can result from the aerosolization suggested by this study.

Although Acinetobacter is capable of surviving in and on dry environments for months, it also thrives in moisture.

When three patients were identified with drug-resistant Acinetobacter in an emergency ICU, a standard epidemiologic investigation followed. The investigation sought to establish links between the three cases, but when common staff, equipment, and devices were evaluated, no link was found.

Even when healthcare workers’ hands were cultured, no Acinetobacter was recovered.

Finally, environmental cultures were performed, and a strain geneti-

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continuing education cally linked to the clinical isolates was cultured from the tap of a hands-free hand hygiene sink. Other environmental cultures, including the bronchoscope cabinet, were also positive for MDR-AB. One control measure implemented was prohibiting use of the hand hygiene sinks so that affected components could be replaced. A change in oral care practices was also made after it was noted that 15 patients who had received oral care with the tap water had tracheal aspirates positive for Acinetobacter. An oral care process the hospital considered dry used sterile water, and the outbreak was contained after the sink correction and the oral care change.22 Ten patients were infected with Acinetobacter in another ICU within a 30-day period. A couple of environmental samples were also positive, but a direct cause was not found. Strict adherence to infection prevention measures was able to stop the outbreak. Hand hygiene with an alcoholbased disinfectant was emphasized.

Appropriate changing of personal protective equipment during the course of patient care was also highlighted.

Finally, the authors also attribute success to physical separation of infected patients from non-infected to make use of mechanical barriers to eliminate transmission.23 In an outbreak showing the importance of medical equipment and the environment in the transmission of Acinetobacter, 11 patients in an open treatment room became infected when hand-held, high-pressure water pumping pulsatile lavage tools used to clean and debride infected wounds sprayed Acinetobacter from a wound into the air and onto adjacent surfaces.24 The CDC now recommends that when performing pulsatile lavage, healthcare workers follow infection-control procedures to minimize aerosols.

Healthcare workers should use personal protective equipment, including

38 | OR TODAY | OCTOBER 2019

fluid-resistant gowns, gloves, surgical masks, eye protection, and shoe and hair covers. Patients should wear surgical masks, and all IV lines should be covered during the treatment.14,24 Caring for a patient with MDR-AB poses little threat to healthcare workers who follow isolation precautions because the pathogen rarely causes serious infections in healthy people.

Pregnant healthcare workers are not at increased risk and can care for colonized or infected patients.

Nevertheless, nurses should be aware that occupational transmission of Acinetobacter can occur. A case of fulminant pneumonia was identified in a nurse who performed endotracheal suctioning of an infected patient who was on a ventilator.10

Prevention Owing to the increased morbidity and mortality from Acinetobacter infections, as well as the lack of treatment options, prevention is crucial. Once A. baumannii becomes endemic in a hospital, it is difficult to eradicate, and conventional infection control measures often cannot stop its transmission.10,21-23 Therefore, all hospitals should have protocols to prevent the transmission of Acinetobacter from infected or colonized patients to other visitors in the healthcare environment.

Clinical staff including nurses, physicians, and respiratory therapists should be thoroughly educated about the ease of Acinetobacter transmission from infected patients or contaminated environments. An important part of this education should be that Acinetobacter seems to be more easily transmitted than methicillin-resistant S. aureus and vancomycin-resistant Enterococcus, likely due in large part to its ability to survive in so many diverse environmental reservoirs.10,15 In addition, environmental personnel must understand the importance of thoroughly cleaning all surfaces touched

by patients and by healthcare workers during routine patient care.14 Although it is widely known that hand hygiene is the key to infection control, adherence to handwashing continues to be a problem in hospitals.

Even with extensive education, the average adherence rates remain dismal.

Careful handwashing is essential to prevent transmission of Acinetobacter.15 See the CDC guidelines for hand hygiene. The transmission of A. baumannii in healthcare facilities can be prevented by carefully following guidelines issued by the CDC in 2006 and the Association for Professionals in Infection Control and Epidemiology in 2010.14,25 In hospitals, the appearance of a single case of MDR-AB should prompt infection control measures.25 All patients known to be infected with MDR, XDR, and/or PDR Acinetobacter should be subject to the following:14,25 • Flagged in the hospital identification system • Placed in a private room if at all possible; otherwise, cohorting with another MDR-AB patient is acceptable • Placed on contact precautions (transmission-based precautions method)14,25 Healthcare workers: • Should wear gowns and gloves when entering the patient’s room • Should wear a mask if a patient has a sputum culture positive for MDR-AB, when contact with respiratory fluids or secretions is anticipated (i.e., a productive cough, emptying ventilator tubing condensation, endotracheal suctioning), and during wound dressing changes on infected patients14,25 Some facilities may choose to perform active surveillance for Acinetobacter by screening on admission all patients with pneumonia or open wounds who were transferred from other healthcare facilities. Active

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continuing education surveillance culture data may be useful to monitor trends in the incidence of Acinetobacter; however, outside of outbreak situations, there is limited evidence to support widespread use of active surveillance culturing.14,25 In an outbreak, nurses caring for patients with MDR-AB should not concurrently care for non-MDR-AB patients. If this is not feasible and a nurse must enter the room of a nonMDR-AB patient, strict adherence to contact precautions is vital, and care should be taken to avoid assigning the nurse to non-MDR-AB patients who are especially immunocompromised, or those with tracheostomies or open wounds.25 One-to-one nursing care should be provided unless the patient is cohorted with other MDR-AB patients.14,25 Procedures such as phlebotomy should be performed by the nurse whenever possible.25 During outbreaks, physicians should see patients with MDR-AB last during rounds if possible. They should wear gowns, gloves, and masks for patient care, and perform hand hygiene after leaving the patient’s room. Respiratory, physical, and occupational therapists and other ancillary staff should be assigned to see only patients with MDRAB. If this is not possible, they should see patients with MDR-AB last, at the end of the day. All other staff should try to see patients with MDR-AB last whenever possible.14 Due to its persistence on environmental surfaces, extra care should be taken with environmental cleaning:14,25 • Single-use or disposable equipment should be used for an MDR-AB patient whenever possible. Pertinent staff must be educated on disinfection methods for nondisposable equipment: X-ray, ECG, dialysis machines, etc.

• Staff assigned to clean rooms of patients with MDR-AB should be educated on the importance of cleaning and the proper use of

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transmission-based precautions.25 During an outbreak of MDRAB:14,25 • Rooms should be cleaned every day with disposable or dedicated cleaning equipment. The surfaces with hand contact are the ones most often contaminated with Acinetobacter. All surfaces should be disinfected with an EPA-registered hospital-grade disinfectant following wet contact times listed on the disinfectant label.

• After discharge of a patient with MDR-AB, the room must be terminally cleaned. Floors, bed, bedside table, telephone, IV poles, call-light buttons, etc., must be disinfected. Bedside curtains must be changed.14,25 • All unused disposable items should be discarded. Other items should be decontaminated. (Acinetobacter can contaminate stock items in a patient’s room.)

• If environmental cleaning staff is prohibited from cleaning certain medical equipment, such as IV pumps and monitors, cleaning should be assigned to other appropriate personnel.

See the referenced guidelines for further information on preventing transmission of Acinetobacter.

The U.S. has one of the highest rates of drug-resistant hospital infections in the world.2 If antibiotics become increasingly ineffective against hospital-acquired infections, practicing modern medicine will become problematic. Surgery, organ transplantation, chemotherapy, hip and knee replacement, dialysis, central venous catheters, and mechanical ventilation all depend on effective antibiotics to deal with the infections that result as adverse effects of treatment. Much of the responsibility for preventing infections falls on nurses. Nurses can help educate other healthcare providers and environmental staff about the critical need

for hand hygiene and the meticulous disinfection of the hospital environment. Working together, they can help control increasing antimicrobial resistance by reducing the transmission of all pathogens.

Connie C. Chettle, MPH, MS, RN, past author of this educational activity, has not had an opportunity to influence the content of this version.

Beth R. Wallace, MPH, CIC, is the manager of infection prevention at Methodist Charlton Medical Center in Dallas, Texas. She is board certified in infection control. She is an active member of the Association of Professionals in Infection Control and Epidemiology, and she has published and presented on a variety of infection prevention and control topics at local and national levels.

References 1. Spellberg B. Why is the antibacterial pipeline drying up? Institute of Medicine Web site. http://iom.nationalacademies.org/~/media/E533F55954364FC980560D9C964B9F25. ashx. Accessed June 25, 2018.

2. Martens E, Demain AL. The antibiotic resistance crisis, with a focus on the United States. J Antibiot (Tokyo).

2017;70(5):520-526. doi: 10.1038/ ja.2017.30.

3. Antibiotic resistance threats in the United States, 2013. Centers for Disease Control and Prevention Web site. http:// www.cdc.gov/drugresistance/threatreport-2013/index.html. Updated April 10, 2017. Accessed June 25, 2018.

4. Peleg AY, Seifert H, Paterson DL. Acinetobacter baumannii: emergence of a successful pathogen. Clin Microbiol Rev. 2008;21(3):538-582. doi: 10.1128/ CMR.00058-07.

5. Camp C, Tatum OL. A review of Acinetobacter baumannii as a highly successful pathogen in times of war. Lab Med. 2010;41(11):649-657. http://www. medscape.com/viewarticle/732915.

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continuing education

Accessed June 25, 2018.

6. Townsend J, Park AN, Gander R, et al.

Acinetobacter infections and outcomes at an academic medical center: a disease of long-term care. Open Forum Infect Dis. 2015;2(1): ofv023. doi: 10.1093/ofid/ofv023.

7. Mortensen E, Trivedi KK, Rosenberg J, et al. Multidrug-resistant Acinetobacter baumannii infection, colonization, and transmission related to

ing_Product_Research_and_Development/Antimicrobials/Statements/ IDSATestimony%20Final%20 with%20references%20060310.pdf.

Published June 9, 2010. Accessed June 25, 2018.

13. Lesho E, Yoon EJ, McGann P, et al.

Emergence of colistin-resistance in extremely drug-resistant Acinetobacter baumannii containing a novel pmrCAB operon during colistin

MB. Addressing antimicrobial resistance and stewardship: the Priority Antimicrobial Value and Entry (PAVE) Award. JAMA. 2017;318(12):11-3-1104. doi:10.1001/jama.2017.10164.

20. Dancer SJ. Controlling hospitalacquired infection: focus on the role of the environment and new technologies for decontamination. Clin Microbiol Rev. 2014;27(4):665-690. doi: 10.1128/CMR.00020-14.

a long-term care facility providing subacute care. Infect Cont Hosp Epidemiol. 2014;35(4):406-411. doi: 10.1086/675612.

8. Aliyu S, Smaldone A, Larson E. Prevalence of multidrug-resistant gram-negative bacteria among nursing home residents: A systematic review and meta-analysis. Am J Infect Cont. 2017;45(5):512-518. doi: 10.1016/j. ajic.2017.01.022.

9. Cunha BA. Acinetobacter. Medscape Web site. http://emedicine. medscape.com/article/236891overview#showall. Updated March 15, 2016. Accessed June 25, 2018.

10. Wong D, Nielsen TB, Bonomo RA, et al. Clinical and pathophysiological overview of Acinetobacter infections: a century of challenges. Clin Micro Rev. 2017;30(1):409-447. doi: 10.1128/ CMR.00058-16.

11. Gonzalez-Villoria AM, ValverdeGarduno V. Antibiotic-Resistant Acinetobacter baumannii increasing success remains a challenge as a nosocomial pathogen. J Pathog. 2016;2016:7318075. doi: 10.1155/2016/7318075.

12. Spellberg B. Testimony of the Infectious Diseases Society of America: Antibiotic resistance: promoting critically needed antibiotic research and development and appropriate use (“stewardship�) of these precious drugs. IDSA Web site. http:// www.idsociety.org/uploadedFiles/ IDSA/Policy_and_Advocacy/Current_Topics_and_Issues/Advanc-

therapy of wound infections. J Infect Dis. 2013;208(7):1142-1151. doi: 10.1093/infdis/jit293.

14. An APIC guide 2010: guide to the elimination of multidrug-resistant Acinetobacter baumannii transmission in healthcare settings. Association for Professionals in Infection Control Web site. http://www.apic. org/resource_/eliminationguideform/b8b0b11f-1808-4615-890bf652d116ba56/file/apic-ab-guide. pdf. Accessed June 25, 2018.

15. Manchanda V, Sanchaita S, Singh NP. Multidrug-resistant Acinetobacter. J Global Infect Dis. 2010:2(3):291-304. doi: 10.4103/0974-777X.68538.

16. Sievert DM, Ricks P, Edwards JR, et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010. Infect Cont Hosp Epidemiol. 2013;34(1):1-14. doi: 10.1086/668770.

17. Ketter PM, Guentzel MN, Schaffer B, et al. Severe Acinetobacter baumannii sepsis is associated with elevation of pentraxin 3. Infect Immun.

2014;82(9):3910-3918. doi: 10.1128/ IAI.01958-14.

18. Wenzler E, Goff DA, Humphries R, Goldstein EJC. Anticipating the unpredictable: a review of antimicrobial stewardship and Acinetobacter infections. Infect Dis Ther. 2017;6(2):149172. doi: 10.1007/s40121-017-0149-y.

19. Daniel GW, Schneider M, McClellan

21. Yakupogullari Y, Otlu B, Ersoy Y, et al.

Is airborne transmission of Acinetobacter baumannii possible: A prospective molecular epidemiologic study in a tertiary care hospital. Am J Infect Cont. 2016;44(12):1595-1599. doi: 10.1016/j.ajic.2016.05.022.

22. Umezawa K, Asai S, Ohshima T, et al.

Outbreak of drug-resistant Acinetobacter baumannii ST219 caused by oral care using tap water from contaminated hand hygiene sinks as a reservoir. Am J Infect Cont.

2015;43(11):1249-1251. doi: 10.1016/j. ajic.2015.06.016.

23. Dettori M, Piana A, Deriu MG, et al.

Outbreak of multidrug-resistant Acinetobacter baumannii in an intensive care unit. New Microbiol.

2014;37(2):185-191. Available at: http://www.newmicrobiologica.org/ PUB/allegati_pdf/2014/2/185.pdf.

Accessed June 25, 2018.

24. Maragakis LL, Cosgrove SE, Song X, et al. An outbreak of multidrug-resistant Acinetobacter baumannii associated with pulsatile lavage wound treatment.

JAMA. 2004;292(24):3006-3011. doi:10.1001/jama.292.24.3006.

25. Siegel JD, Rhinehart E, Jackson M, et al. Management of multidrug resistant organisms in healthcare settings (2006). Centers for Disease Control and Prevention Web site. https://www.cdc.gov/infectioncontrol/guidelines/MDRO/index.html.

Updated April 5, 2017. Accessed June 25, 2018.

40 | OR TODAY | OCTOBER 2019

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Clinical Vignette Amy, an ICU nurse, is assigned a patient on a ventilator who has been diagnosed with an MDR-AB. Amy asks her manager for information.

1. What should the manager tell Amy about A. baumannii?

a. Not much is known about it. b. I t is a cause of hospital-acquired pneumonia and easily treated with antibiotics. c. I t is a hospital-acquired airborne fungal infection that mainly infects immunosuppressed patients. d. Acinetobacter is a major multidrug-resistant, hospitalacquired pathogen that can survive in the hospital for extended periods.

2. Amy asks what isolation precautions are needed to care for her patient and how she can protect herself. Her manager says:

a. B ody-substance isolation is sufficient to control the transmission of MDR-AB. b. You should use transmission-based (maximum) precautions, including gown and gloves, when entering the room. Use a mask when caring for patients with positive sputum cultures. c. You should use standard precautions, the same as for all patients. d. You should practice good handwashing, especially between caring for this patient and a patient being treated for neutropenic fever.

3. Amy wonders about her other patient, who was immunosuppressed during the outbreak of MDRAB. The manager says:

a. I deally, you should not care for a non-MDR-AB patient while caring for a patient with MDR-AB. b. H andwashing will prevent transmission of infection to the immunosuppressed patient. c. F ollow airborne precautions. Keeping the MDR-AB patient’s door closed should prevent transmission. d. Continue with both assignments.

Clinical VignettE ANSWERS 1. D - Acinetobacter can survive up to five months on inanimate surfaces. Transmission via the contaminated environment can occur. 2. B - A patient with MDR-AB should be placed in a private room unless cohorted with others with MDR-AB. Healthcare workers should wear gowns and gloves when entering the patient’s room. They should wear masks if the patient has Acinetobacter in sputum. 3. A - One-to-one nursing care should be provided for a patient with MDR-AB unless the patient can be cohorted with other patients who have MDR-AB during an outbreak. Nurses caring for patients with MDR-AB should not enter the rooms of noninfected immunocompromised patients.

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Deadline Courses must be completed by 8/31/2020 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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CORPORATE profile

Healthmark

Healthmark Industries

50 Years and Beyond Healthmark Industries has had an exciting year and is looking forward to an exciting future with its continued expansion of staff and innovative products. This year marks the company’s 50th anniversary.

Over the years, the company has experienced a great deal of growth with a variety of products and services. Known for providing innovative solutions for infection control to health care facilities, Healthmark Industries is currently expanding its product line. The company has over 200 employees and has moved to its headquarters that is an overall size of around 100,000 square feet in Fraser, Michigan.

Healthmark Industries was established in 1969 in Grosse Pointe, Michigan, by Ralph A. Basile and his wife, Suzanne. After a successful career in medical sales, Ralph

44 | OR TODAY | OCTOBER 2019

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 avenues in St. Clair Shores. From the beginning, 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. As time went on, each of the sons, at different times and with different prior experiences, joined the family business and helped it grow. 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, grand-

children and many loyal employees, the company has continued to grow.

Over the years Healthmark has expanded its product line to fit the needs of health care facilities and one of the product lines that they added to is optical products. One of the newest products that just launched is the Flexible Inspection Scope (FIS-006). It features a distal tip composed of a light source and camera lens at the end of a 110cm, flexible shaft. Designed for lumens 1.18 mm in diameter or larger. The camera and light are powered by the USB connection on a PC. Compatible with computers running Windows 7, 8 and 10, the included software allows viewing and recording.

Cleaning verification continues to be an important issue in health care across the country. News headlines often report about complications from surgeries caused by instruments and equipment that have not been properly cleaned. It has affected the health care field in recent years.

Healthmark added products to WWW.ORTODAY.COM

SPECIAL ADVERTISING SECTION

Members of the Basile family are (back row, from left) Ralph Basile, Dan Basile, Mark Basile and Theresa Basile; and (front row, from left) Suzanne Basile, Karen Mac Donald-Basile, Delores Basile, Lily Basile, Steve Basile and Pete Basile.

its ProFormanceTM monitoring tools over the years to help ensure surgical instruments and other equipment are reprocessed correctly.

AAMI1 and AORN2 recommend at least weekly testing of the cleaning process. These products are designed to help facilities comply with standards and ensure they are reprocessing equipment and cleaning surgical instruments properly.

“One of the ongoing challenges in the health care industry is to effectively reprocess surgical instruments on a consistent basis,” says Ralph Basile, vice president.

Healthmark has products designed to help hospitals and health care facilities provide safe environments and prevent infections.

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Researchers have discovered that devices that haven’t been reprocessed correctly can emerge from the cleaning process with bits of bone, blood and tissue from the previous operation. These contaminants can be reservoirs for some potentially lethal bacteria. Proper cleaning and sterilization are essential for ensuring that medical and surgical instruments do not transmit infectious pathogens to patients.

According to the Centers for Disease Control and Prevention (CDC), multiple studies in many countries have documented lack of compliance with established guidelines for disinfection and sterilization. Failure to comply with scientifically based guidelines has led to

numerous outbreaks.

“Our ProFormanceTM products are designed to help hospitals and healthcare facilities meet the challenge to regularly test their cleaning process in order to ensure their medical devices are being reprocessed properly. Once reprocessed, inspection will need to take place to ensure the surgical instruments are indeed clean,” Basile explained.

Healthmark also launched a new software application this year, ProFormanceQA™ 2.1 to its ProFormance™ Cleaning Verification product line. This database that Healthmark offers for free for their ProFormance™ product customers.

It’s a secure online database that allows professionals to record key OCTOBER 2019 | OR TODAY |

45

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statistics for the performance of decontamination procedures, including the test results from Healthmark’s ProFormance™ line of monitoring products. With this cloud-based database professionals can record data, use the information to generate impactful reports and track equipment cleaning performance over time.

To begin the setup process go to https://www.proformanceqa.com.

Then, please call 800-521-6224 ext. 6657 or email proformanceqa@ hmark.com to schedule a call with the ProFormanceQA Help Desk.

Look for Healthmark’s newest online game this fall on Crazy4Clean.com. It is another unique free service that Healthmark offers.

Crazy4Clean.com is a website that consists of educational games designed to teach health care professionals about proper reprocessing of instruments/equipment while earning free CEUs. “Games are a great way to learn.

They simulate experiences that teach you new skills while you’re entertained,” said Basile. “This will be the15th game we have launched on Crazy4Clean.com and we are very excited for everyone to play it online.”

46 | OR TODAY | OCTOBER 2019

Our ProFormance™ products are designed to help hospitals and healthcare facilities meet the challenge to regularly test their cleaning process in order to ensure their medical devices

"

are being reprocessed properly.

At the end of each game, players receive a free CEU by completing a quiz based on what they’ve learned.

If you are looking for industry news, helpful hints and other information, Healthmark produces a weekly newsletter that is distributed to thousands of readers. Each Healthmarket Digest features a story written by a member of the Healthmark team as well as a weekly coupon.

For more information about Healthmark Industries, visit www.hmark.com or call 800-521-6224.

References 1. AAMI (ST79 Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities) 2. AORN Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment

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By Don Sadler

S

terilization is one of the most critically important aspects of patient safety today. This underlines the vital role played by sterile processing in today’s health care environment.

Kimberly Smith, MS, RN, CNOR, CRCST, the owner of KAS Sterilization Solutions, says that sterile processing department (SPD) personnel are “full partners in a facility’s infection control plan to ensure that patients are not exposed to potentially infective conditions.”

“

”

We are weapons of mass microbial destruction. Our mission is to provide functional surgical tools on time and sterile for every procedure in which they are required.

— Hank Balch

These personnel are responsible for providing “clean, functioning and sterilized disinfected instruments for patients undergoing invasive procedures or surgery,” Smith adds. “In addition, they are responsible for performing quality control monitoring of the equipment and processes involved in reprocessing instrumentation.”

Weapons of Mass Microbial Destruction Hank Balch, the founder and president of Beyond Clean, is a little more colorful in his description of SPD. “We are weapons of mass microbial destruction,” says Balch. “Our mission

is to provide functional surgical tools on time and sterile for every procedure in which they are required.”

“Although sterile processing is often misunderstood, it plays a critical role in today’s health care environment,” adds David Taylor, MSN, RN, CNOR, president of Resolute Advisory Group LLC. “Sterilization and sanitation are of utmost importance as it relates to patient safety.”

Smith believes that the body of knowledge and research related to sterile processing is currently offsetting past decades of inattention. “However, sterile processing is still at the mercy

of vague manufacturer instructions for use (IFUs), instruments that can’t be disassembled for cleaning, and a lack of clear productivity benchmarks that are understandable and universally accepted.”

There is a wide range of potential negative consequences that can arise from poor sterile processing practices.

According to Smith, these include: • Increased potential for surgical site infections (SSIs); • Increased surgery times and time under anesthesia; • Decreased surgical caseload and revenue if cancellations are related

“

The key to a successful quality assurance and sterilization monitoring program begins with leadership.

— David Taylor

to compromised or unavailable instruments; and • Increased instrument maintenance and replacement costs.

Taylor says hardly a month goes by without a news item about problems due to a health care facility failing to meet sterilization standards. A few of these high-profile stories include: • A North Carolina hospital that washed instruments in hydraulic fluid.

• A New Hampshire hospital where patients were told that non-sterile surgical equipment may have exposed them to brain disease.

• A superbug found at a suburban Chicago hospital where health officials are taking steps to prevent the spread of CRE. • A hospital in Milwaukee where contaminated instruments are the suspected culprits in staph infections contracted by five women during their surgeries.

In addition, as many as 12,000 young adults and children treated at a Seattle clinic and surgery center since 2010 could be at risk of infection from surgical instruments that may not have been properly sterilized. And, 293 patients at a hospital in Massachusetts have possibly been exposed to hepatitis since 2016.

Taylor believes that current practices, a lack of education and training, and engineering factors keep sterile processing from being a high-reliability department. “Medical errors are the third-leading cause of death in the U.S. and proper sterilization plays a huge role in reducing errors and thus improving patient safety,” he says.

52 | OR TODAY | OCTOBER 2019

Best Practices in Sterilization Given the many potential problems associated with poor sterilization, it’s critical that health care organizations take a fresh look at this area and adopt best practices that have been proven to improve sterilization.

As with many things associated with improving health care and patient safety, improving sterilization practices starts at the top of the organization, says Taylor.

“The key to a successful quality assurance and sterilization monitoring program begins with leadership,” he says. “Number one, do leaders have the knowledge and understanding of the various sterilization quality assurance guidelines? And number two, is that knowledge transferred to the staff?”

The primary sources to provide a foundation of sterilization knowledge are ANSI/AAMI ST79 and AORN’s Recommended Practices for Sterilization, Taylor adds.

“The real need in our industry has been and remains continuing education,” says Balch. “This is by far the most important and transformative action that SPD and OR teams can take to improve their current state of reprocessing.”

However, this is one of the most difficult and time-consuming actions, which is why it’s so often left undone, Balch adds.

“It’s easy to talk about better communication and increased collaboration,” Balch says. “But, if these things are not undergirded by actual knowledge, then we are only communicating and collaborating about

David Taylor, MSN, RN, CNOR president of Resolute Advisory Group LLC myths, misconceptions and personal preferences.”

Smith has her own list of sterilization best practices that starts with improving point-of-use cleaning practices. “All users of instrumentation share in the responsibility for cleaning and maintaining instruments,” she says.

Smith also recommends removing excess and unnecessary instrumentation from sets because these create wasted work. “And be sure to purchase an appropriate number of instruments to eliminate supposed ‘rapid turnover’ sets and items,” she says. “No part of the processing continuum can be minimized or circumvented.”

Most importantly, Smith stresses the importance of treating instrument sets like any other asset required for surgery. This includes the surgeon, anesthesia provider, circulating nurse or scrub tech, and the operating room itself.

“If you only have four ACL sets, don’t schedule five ACL surgeries,”

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says Smith. “Every moment spent reprocessing ‘rapid turnover’ items for today is less time spent on preparing instruments, case carts and supplies for tomorrow’s schedule.”

Unique Sterilization Challenges According to Taylor, the most difficult instruments to reprocess are those that have complex designs and various validated IFUs. “For the most part, most SPDs have standardized cleaning procedures,” he says.

“However, instrument complexity or the size of instrument sets – such as orthopedic, spine and delicate instruments like ophthalmic sets – require specific detailed cleaning and reprocessing instructions that are not consistent from one manufacturer to another,” Taylor adds. “This further complicates the process.”

Central to any sterile processing quality management program is the need to document every aspect of the workflow, says Balch.

“I’m talking about from point of use through decontamination and on through the process,” he says.

“Unfortunately, there are currently very few aspects of the instrument workflow that are consistently documented in most SPDs.” Balch believes there are opportunities for SPDs to increase their documentation capabilities through digital tracking software that’s currently on the market. “While these programs are often called ‘instrument tracking systems,’ I think a better term for them would be ‘surgical asset management platforms,’ ” he says.

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Kimberly Smith, MS, RN, CNOR, CRCST owner of KAS Sterilization Solutions

OR and SPD Cooperation is Critical Finally, the importance of cooperation between OR and SPD personnel cannot be overstated. “One of the problems is that neither department truly understands or appreciates the work required of the other,” says Smith.

“I’ve had some success in exposing SPD personnel to surgical procedures by having them actually watch a surgery or having a surgeon present an inservice to SPD using instruments utilized for a specific procedure,” Smith adds. “This provides direct knowledge to the SPD tech of how and why a specific instrument is utilized.”

Smith has also had OR techs and nurses spend a full day in SPD so they can witness all of the activities required to inspect and functionally test each instrument. “The leaders of each department need to respect the duties and responsibilities of the other and set this kind of tone for the staff each and every day,” says Smith.

Taylor concurs: “I call it ‘walk a mile in my shoes,’ ” he says. “If we don’t understand the other person’s perspective, how can we deliver quality health care?”

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Laura Cornelis, SPOTLIGHT ON:

MSN, APRN, FNP-BC

BY M AT T S KO U FA LO S

When Laura Cornelis decided to pursue a career in health care, her life was at a crossroads. Newly divorced with two young children, she balanced parenting, work and her education. Very few of those pulls on her attention relented; all-nighters were common, and if her children took sick and there was no one else to watch them, she had to bring them to class. Yet, Cornelis was determined to stick it out.

“It was rough, but nobody in my family ever went to college, and my parents didn’t graduate from high school,” she said. “It was a huge accomplishment for me.”

Cornelis began her schooling in the surgical technician certificate program at Camden County College in New Jersey, but Jennifer Hoheisel, a philosophy professor in her bioethics course, encouraged her to switch to a nursing track.

“She approached me and asked why I was in the [certificate] program,” Cornelis said. “I didn’t understand that there were options for me. I was just looking at what would be quick and what would be affordable.”

Hoheisel encouraged Cornelis to “just apply, and worry about how you’ll pay for it later.” Cornelis followed that advice, and wound up getting offers from five differ-

56 | OR TODAY | OCTOBER 2019

ent schools. Drexel University in Philadelphia, Pennsylvania offered her a dean’s scholarship for every year she maintained a 3.5 GPA, and she kept up her average.

A year into the program, however, she suffered a head injury, and its lingering aftereffects forced her to quit school and change her major to health administration.

She did graduate, and then once her symptoms were controlled, returned to complete her nursing degree – all while working. Drexel places its students in a co-op workstudy program, which gives them classroom and vocational experience in equal measure throughout the calendar year, but Cornelis was well familiar with managing the variety of demands on her time.

Still, that didn’t make it any easier; what got her through was a determination to complete her course

of study, and a genuine love of the course material.

“It sounds silly, but two things that I like a lot are people and problems, and I feel like nursing is the best combination of both of those things,” Cornelis said. “You get to talk to people all day and be with them and help them, a lot of times at the worst time of their life, and you’re helping them try to

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Laura Cornelis loves spending time with her family.

figure out their problems. It’s part social work, part detective.”

After graduating, Cornelis took a job at Jefferson University Hospital, also in Philadelphia, working with head and neck cancer patients. It was the setting in which she honed her patient education skills.

“You’re dealing with people who are having life-altering,

WWW.ORTODAY.COM

disfiguring surgeries,” Cornelis said. “Sometimes they would lose their ability to speak from mouth and throat cancer; they would sometimes lose their tongue, lose their larynx, and it would be lifechanging.”

After six years, Cornelis decided to return to school to pursue a master’s degree, which she earned through distance learning at Sim-

mons College in Boston, Massachusetts. From there, she spent a year-and-a-half working in primary care in southern New Jersey, an environment Cornelis described as “the med-surg of being a nurse practitioner.”

“I loved it,” she said. “Working in primary care, you see everything; you do it all. The part I didn’t love about it was the pace. You’re

OCTOBER 2019 | OR TODAY |

57

D MANY “I’VE HA YOU S S AY, ‘ PAT I E N T E TOOK TH R E A L LY T H AT XPLAIN E O T E TIM ONE OR, ‘NO ,’ E M O T H A T .’

LD ME T EVER TO T TO VE A LO A H S E S NUR Y IN PECIALL S E , R E F OF WHERE Y CARE, R A M I R P AND IS THE DEM IT’S GH, AND I H Y L L REA INUE O CONT T G N I O G W .”

TO GRO

seeing 25 to 30 patients a day, and it’s really hard to spend time with people.”

When the opportunity arose to work in a more hands-on setting, Cornelis and her family relocated to Naples, Florida, where she took on a visiting nursing role with PopHealthCare in the Fort Myers area. It represents a big change from her prior experiences: she’s driving more, taking longer appointments with patients, and observing them in their home environments, which adds another dimension to her diagnostic efforts.

The service is delivered in partnership with health insurer Florida Blue.

“I tell my patients even if you think you don’t need it, this is the closest thing you’re going to get to concierge medicine without being rich,” Cornelis said. “It’s almost like the old days when doctors did house calls. I get to really sit down and spend time with people, and you see them in their element; things that you would never really

58 | OR TODAY | OCTOBER 2019

see if you saw them in the office. I like that aspect of it.”

All this work is done in service of limiting hospitalizations for patients who have had recent hospital stays, or who face complicated medical conditions, via personalized, intervening, primary care. Cornelis said the practice is not unlike the early days of frontier medicine, when nurses on horseback would travel to rural and distributed areas to provide in-home care for patients farther removed from centralized treatment options.

“I think that’s where nurses with advanced degrees are really going to come in handy,” Cornelis said. “There are so many areas just lacking health services, [and] rural health care is huge right now. I think that’s definitely going to be a huge area of need.”

Home health care is an aspect of practice in which Cornelis believes her training as a nurse helps expand the quality of service she can provide to her patients. Its emphasis on communication and bedside manner has helped her build a meaningful rapport with

those in her care.

“I think nurses with advanced degrees bring a totally different element to health care,” Cornelis said. “I’ve had many patients say, ‘You really took the time to explain that to me,’ or, ‘No one ever told me that.’ Nurses have a lot to offer, especially in primary care, where the demand is really high, and it’s going to continue to grow.”

Cornelis doesn’t believe she’s finished with her own professional growth, either; she’s already looking into nursing doctorate programs, and can easily foresee a teaching role in her future.

“I didn’t like school as a kid, but I like school now,” she said. “Where I grew up, I didn’t know anybody that went to college as a kid.

Neither one of my parents went to college, but I always knew it was something I wanted to do. Now, I’ve got this bug in my ear to start teaching.”

Would you like to nominate someone for the spotlight article?

Visit ortoday.com/nominations/

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OUT OF THE OR

OUT OF THE OR

fitness

fitness

Intermittent Fasting & Exercise

By Miguel J. Ortiz here is a big weight-loss fad going around known as intermittent fasting. There are some benefits, and it can help with losing weight. Intermittent fasting can create quality behaviors around eating and general discipline. Adding exercise can really fire up your metabolism. Keep in mind this isn’t a fad diet, it is more of a general term for various eating diet plans that cycle between a period of fasting and non-fasting within your day. So, how does it work and how can one appropriately apply exercise to an Intermittent fasting routine?

T

First, fasting has been around for quite some time, especially as a religious practice. If you have not tried fasting before, make sure to consult your nutritionist, dietician and/or physician prior to beginning any type of fasting.

The reason intermittent fasting works well, especially in the morning, is because without food your body will begin using body fat and carb storage (pending on the type of exercise) to

WWW.ORTODAY.COM

burn calories and can drive up other metabolic functions, which in turn increases your metabolism. Now, this sounds great from a weight loss perspective. However, when we start adding exercise we need to make sure we understand where we are within our health and fitness journey. Exercising on an empty stomach can cause some blood sugar issues. So, again, speak to your physician and or dietician/nutrition coach before starting something like this. And, consider these three tips when adding exercise to your fasting routine.

One, start with light stretching and general light activity, maybe some Pilates or yoga. Light walking around the neighborhood or on the treadmill is fine as well. Perhaps, some light strength training will work. Just make sure everything you do is under control and that you take your time.

Two, during all training types, and regardless of type of activity, quality breathing throughout all movements ensures good oxygen intake and keeps your heart rate under control. Hydration should be considered to allow quality muscle, joint and neuromus-

cular function as hydration allows the body to move quite fluidly.

Three, during strength training make sure that you’re getting quality rest between sets. Be mindful of circuit training if you’re not used to it. If you feel like your heart rate is getting too high, you may want to slow down or even sit down to allow easier blood flow.

Follow these tips when exercising while in a fasted state and you’ll enjoy your results while you absolutely kick start your day. I recommend doing exercise first thing in the morning if you’re doing it fasted. If you are used to the fasting and you tend to do exercise in the afternoon, just ensure quality hydration and a good post workout shake and meal before getting back to your day. Good luck and have fun with your fitness journey!

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.

OCTOBER 2019 | OR TODAY |

61

OUT OF THE OR health

7

Tips for Healthy Grocery Trips

By EatingWell.com ood manufacturers are recognizing Americans’ interest in healthy eating, and there are plenty of healthy, delicious foods in almost every aisle of the supermarket these days. Use these tips to focus on healthy selections for your whole family. If your kids are old enough, get them involved in choosing healthy items and navigating the store aisles to find the healthy stuff. It can be fun and will help them develop healthy eating patterns for life.

F

1. Cereal aisle: It’s no secret that prime real estate in the cereal aisle is at children’s eye level, so they can easily spot the sugary cereals and beg Mom and Dad to buy them. Try to resist – there are plenty of healthier options that still satisfy a sweet tooth.

Be sure to look for whole-grain cereals that are high in fiber – 5 grams or more – and cereals that have less than 9 grams of sugar per serving.

2. Dairy section: Choose low-fat dairy options over whole milk and full-fat varieties; they usually have all the same nutrients and benefits without all the fat. Individual packs of cottage cheese and yogurt make great snacks, as do low-fat string cheese and

62 | OR TODAY | OCTOBER 2019

individually wrapped cheese squares.

Yogurts can be high in added sugar, so be sure to read the label and pick those with little added sugar. Take advantage of lunchtime as a great opportunity to give your kids natural sources of calcium.

3. Juice aisle: Only buy 100% juice and avoid other beverages that include such ingredients as high-fructose corn syrup, artificial color and artificial flavor.

4. Frozen section: Bags of frozen fruit and vegetables can come in handy when you’re out of fresh produce. Frozen berries can be mixed into yogurt or cereal. Frozen veggies are great in stir-fries and casseroles.

5. Produce section: Go for variety.

Buying the fruit and vegetables your children like assures that they’ll eat plenty of them, but what about trying ones they’ve never even heard of?

How about jicama, papaya, tomatillos, mango or even artichokes? Look for what’s in season and don’t be afraid to try something new. Prewashed and peeled veggies, such as mini carrots or celery sticks, make great snacks.

Apples, pears, peaches, oranges and bananas are lunchbox-ready, but any fruit is easy to pack – simply cut it

up and put it into little single-serving containers.

6. Soda aisle: Keep walking! But, if your kid loves the fizz and carbonation, consider flavored seltzer waters – they have zero calories and zero sugar.

Or make your own spritzer by adding a splash of 100% fruit juice to seltzer.

7. Snack-food aisle: This can be a tough aisle with all the options out there: a zillion potato chips, pizzaflavored tortilla chips and sugar-laden cookies and bars – with new ones filling the shelves every day. Weeding out the good from the bad is a challenge, but here are some tips to get you started: • Go for baked instead of fried potato chips or corn chips.

• Limit portion size; a 1-ounce portion is plenty.

• Avoid foods with partially hydrogenated oil listed in the ingredients list; these are unhealthy trans fats.

• Chose whole-wheat pretzels and whole-grain crackers over varieties made with refined flours.

• Look for granola bars that contain whole grains, nuts, seeds and pieces of dried fruit.

• Introduce your kids to snacks made of whole foods, such as nuts, dried fruit, trail mix and fruit leather.

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OUT OF THE OR EQ Factor

Two Ingredients for Motivating Your Team By daniel bobinski n your career, have you noticed that some teams are more motivated than others?

Motivated teams rarely happen by accident. Let me give you two suggestions for putting emotional intelligence into action to help get your team motivated.

I

1. Get to know the people on your team. What do they value? What are their interests? What do they care about?

2. Make sure your team has a clear vision and mission – a distinctly identifiable purpose. And make sure you know what that purpose is.

You might say, “But I already know the people on my team.” Maybe you do. However, I conduct a lot of management training, and when people get honest with me, most admit they don’t know much about their coworkers.

The word motivation means, “A reason to move,” and people move for their reasons, not ours. This will sound simple, but a great way to learn what motivates others is by asking questions.

For example, maybe someone on your team is named Sarah, and through ongoing conversations you

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learn she’s deeply into health and fitness. Or maybe there’s a guy named Mike who’s all about playing the stock market.

When people say they can’t figure out what motivates others, my response is almost always the same: “Have you asked?”

The second point is knowing your team’s distinct purpose and being able to articulate it. When I ask five different team members about the purpose of their team, I usually get five different answers. There needs to be a common purpose, and that purpose needs to be known by all.

When you know what drives people and can articulate your team’s purpose, it’s easier to paint a picture for them, showing how their personal interests and values align with the purpose of the team.

Going back to our examples, when talking with Sarah I might draw a comparison that when each team member gets healthy input from other team members, then everyone can operate at peak performance together to achieve the team’s purpose. When talking with Mike, I might underscore the importance of analyzing trends and factors that impact the team’s bottom line, so we can make good decisions moving forward.

Just know that none of this happens in only one conversation. We’re talking about themes and ideas that must be regularly strengthened and reinforced.

You might say, “But I’ve told everyone our vision and mission, why do I need to tell them again?” To that I say, “You ate yesterday, and the day before that, and the day before that, right? Why do you need to eat today?”

Wouldn’t that be the same logic?

Like all living creatures, people thrive in some environments while they wither in others. With that in mind, remember that teams are stronger when everyone is united in purpose, and reinforcing that unity must be an ongoing process.

Connect people’s interests to your team’s purpose and your team is likely to be more motivated.

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.

OCTOBER 2019 | OR TODAY |

65

OUT OF THE OR nutrition

Stress and Eating

By Charlyn Fargo t’s amazing that a little extra stress in your life can result in a few extra pounds. As the cortisol increases, so does our tendency to gain weight. The more stressed we are, the more likely we are to grab something – anything – and it may not always be the healthiest option.

Maybe that’s why our Apple watches tell us to “breathe” and why yoga classes are now so trendy. It’s so important to find a way to reduce the stress in our lives.

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Stress has other consequences as well – even for your kids. The right nutrition can help ward off anxiety and lessen the strain. (And by the way, it works for adults as well.)

Providing your kids a balanced diet will help them cope with new schedules, new teachers and new learning experiences. Studies have linked improper nutrition with inability to focus, anxiety and even depression in children and teens.

Healthy eating has a positive effect on grades and test performances, according to the Centers for Disease Control.

Start with a healthy breakfast and follow up with a lunch that’s packed

66 | OR TODAY | OCTOBER 2019

with at least two of these food groups: fruits and vegetables, lean protein, whole grains, low-fat dairy and healthy fats. Make a peanut butter sandwich on whole wheat-bread – try adding fresh berries or bananas instead of jelly – pack some grapes, carrot sticks and hummus and low-fat milk. Or how about a trail mix (with healthy nuts and seeds) with a kiwi and some lowfat Greek yogurt?

It helps to change things up – different fruits and vegetables, different lean protein, different whole grains.

Serve fruits and veggies that contain vitamin C, which can help keep kids’ immune systems healthy. Whole grains offer fiber, which helps keep blood sugar steady. Tuna can be a great source of protein and healthy fat, which allow bodies to absorb vitamins.

Combine tuna with yogurt (instead of mayo) and add some lettuce or tomatoes. Or send a fruit, veggie and cheese plate.

Think about whether the snacks you’re packing for lunch offer protein and fiber. (That’s the key to choosing a healthier snack.) Potato chips don’t, but Harvest Snaps or Beanitos – made from peas and beans, respectively – do.

If you want to add dessert, try frozen grapes and an oatmeal or peanut butter cookie.

The end result may be a happier, less stressed student making better grades.

Q: Does fluid from foods count toward water intake?

A: Absolutely. Some 20% of our fluid intake may come from fluid-rich foods, such as fruits, vegetables and dairy products. However, the majority (80%) of water intake should come from drinks. Water is best, but you can also choose other beverages (just limit the ones with sugar, additives, caffeine and artificial ingredients).

Warmer temperatures, exercise and age increase the need for more hydration. Some symptoms of being dehydrated include increased thirst, headache, constipation, dry mouth, dry skin, sudden weight loss, muscle fatigue and feeling sleepy. A good way to stay hydrated is to keep a glass of water handy.

Charlyn Fargo is a registered dietitian at Hy-Vee in Springfield, Illinois, and the media representative for the Illinois Academy of Nutrition and Dietetics. For comments or questions, contact her at charfarg@aol.com or follow her on Twitter @NutritionRD.

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OUT OF THE OR

Recipe

recipe

the

68 | OR TODAY | OCTOBER 2019

Spiced Sweet Potato Chocolate Bundt Cake ingredients For the cake: • 1 1/2 pounds orange-fleshed sweet potatoes (sometimes called garnet yams) • 3 1/3 cups all-purpose flour • 2 cups sugar • 1 tablespoon baking soda • 1 tablespoon ground cinnamon • 1 tablespoon ground allspice • 1 tablespoon grated nutmeg • 1 tablespoon ground ginger • 1/2 teaspoon kosher salt • 4 eggs • 1 cup unsalted butter, melted and slightly cooled • 2 cups chocolate chips

• • •

•

For the Chocolate-Chicory Glaze: 10 ounces bittersweet chocolate, finely chopped 1 1/2 cups heavy cream 1/2 cup brewed chicory coffee (substitute with regular coffee if you can’t find chicory) 1 cinnamon stick

BY Diane Rossen Worthington Diane is an authority on new American cooking.

She is the author of 18 cookbooks, including “Seriously Simple Parties,” and a James Beard Award-winning radio show host. You can contact her at www.seriouslysimple.com.

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OUT OF THE OR recipe

Gooey Glazed Cake

A Fall Favorite s the weather cools I start thinking of produce like winter squash, sweet potatoes, apples and pears. Seasonal fruits and vegetables available make it a little easier to say goodbye to vibrant summer produce, and I’m ready to start spending more time cooking and baking.

I was searching for a Seriously Simple cake to show off fall’s produce, and I came upon this recipe in Tanya Holland’s book “Brown Sugar Kitchen” (Chronicle Books, $29.95). Sweet potatoes and chocolate chips may seem like an unlikely combina-

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tion, but they work really well together. I also thought it would be a perfect dessert to serve family and friends on Halloween.

After all, it’s orange and black (if you add the chocolate glaze). It’s a large Bundt cake that will feed a crowd. But don’t limit this to Halloween. I’ll be serving this throughout the holidays, perhaps for brunch, tea or dessert.

This cake is slightly dense with a faint sweet potato flavor and is studded throughout with chunks of chocolate. Serve with pumpkin ice cream, if desired.

Spiced Sweet Potato Chocolate Bundt Cake Serves 12 to 16 1.

2.

3.

4.

5.

6.

7.

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Preheat the oven to 425 F. Place the sweet potatoes on a lined baking sheet and bake for 1 hour or until tender. Cool. Cut in half and scoop out the pulp and mash in a small bowl.

Reserve.

Decrease the oven to 350 F. Butter and flour a 12-cup Bundt pan.

In a medium bowl, whisk together the flour, sugar, baking soda, cinnamon, allspice, nutmeg, ginger and salt.

Using a stand mixer fitted with the paddle attachment, beat the mashed sweet potatoes and eggs on medium speed until smooth. Add the melted butter and beat until combined.

Reduce the speed to low, and slowly add the flour mixture; mix just until combined. (Be careful to keep on low so flour stays in bowl.) Remove the work bowl from the mixer and, with a spatula, stir in the chocolate chips. Transfer the batter into the prepared Bundt pan.

Bake until a toothpick or skewer inserted into the center of the cake comes out clean, 40 to 50 minutes. Transfer to a wire rack to let cool completely in the pan, about an hour. Loosen the cake from the pan using the tip of a dinner knife, then invert a rack over the pan and turn the cake out onto the rack.

Make the chocolate-chicory glaze: Put chocolate in a heatproof bowl. In a small saucepan, combine cream, coffee and cinnamon stick; bring to a simmer over medium heat. Pour hot cream mixture over chocolate. Let stand, undisturbed, for about 2 minutes. Discard cinnamon stick; whisk until chocolate is completely melted and mixture is blended and smooth.

Drizzle the chocolate glaze over the cake and serve

OCTOBER 2019 | OR TODAY |

69

OUT OF THE OR pinboard

OR TODAY

• CONTEST • OCTO B E R

TAKE YOUR BEST

WIN LUNC

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

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

YOU could be the next winner!

H!

The Winner Gets a $50 Subway Gift Card!

e up and we should iv g t no d ul o sh e “W lem to defeat us.” not allow the prob – A. P. J. Abdul Kalam

OR TODAY THIS MONTH'S CONTEST WINNER Submitted by:

Chandra Rams, RN , RN; uzawa S is v a Tr nd right: , ST; a Left to nelle Cateil ayani, ST. gb Sha ldan-A ha Ro s a t a N

70 | OR TODAY | OCTOBER 2019

Operating Room Supervisor, Perioperative Services Kapi’olani Medical Center for Women & Children Honolulu, HI

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The News and Photos

that Caught Our Eye This Month

OUT OF THE OR pinboard

RYE IS HEALTHY, THANKS TO AN INTERPLAY OF MICROBES Eating rye comes with a variety of health benefits. A new study from the University of Eastern Finland shows that lactic acid bacteria and gut bacteria contribute to the health benefits of rye. Published in Microbiome, the study used a metabolomics approach to analyze metabolites found in food and the human body.

Rye sourdough used for the baking of rye bread is rich in lactic acid bacteria. In addition to fermenting the dough, these bacteria also modify bioactive compounds found in rye. They produce branched-chain amino acids and amino acid-containing small peptides, which are known to have an impact on insulin metabolism, among other things.

Many of the compounds found in rye are processed by gut bacteria before getting absorbed into the body. The study found that gut microbes and microbes found in sourdough produce compounds that are partially the same.

However, gut microbes also produce derivatives of trimethylglycine, also known as betaine, contained in rye. An earlier study by the research group has shown that at least one of these derivatives reduces the need for oxygen in heart muscle cells, which may protect the heart from ischemia or possibly even enhance its performance. The findings can explain some of the health benefits of rye, including better blood sugar levels and a lower risk of cardiovascular diseases.

The study used metabolomics as the primary method to carry out an extensive analysis of metabolites found in food and the human body.

The effects of gut microbes were studied in mice and in an in vitro gastrointestinal model, mimicking the function of the human gut. Using these two models, the researchers were able to eliminate naturally occurring differences in the gut microbiome between different individuals, making it easier to detect metabolites actually originating from rye.

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Rye can be traced back to what is now known as present-day eastern Turkey, from where it has spread to many cuisines across the world. In Finland, for example, rye has been consumed for thousands of years, and it was recently selected as the country’s national food.

Although the health benefits of rye are long known, the underlying mechanisms are still poorly understood. For instance, the so-called Rye Factor refers to the lower insulin response caused by rye than, for example, wheat bread.

Eating rye makes blood sugar levels fall slower, which leads to beneficial effects on health – for a reason that remains unknown.

A significant factor contributing to the health benefits of rye are its bioactive compounds, or phytochemicals, which serve as antioxidants. In addition, gut microbes seem to play an important role in turning these compounds into a format that can be easily absorbed by the body, making it possible for them to have a greater effect.

“The major role played by gut microbes in human health has become more and more evident over the past decades, and this is why gut microbes should be taken very good care of. It’s a good idea to avoid unnecessary antibiotics and feed gut microbes with optimal food - such as rye,” Researcher Ville Koistinen from the University of Eastern Finland notes.

OCTOBER 2019 | OR TODAY |

71

INDUSTRY INSIGHTS

ORTL Scrapbook

SURGICAL CONFERENCE

OR TODAY LIVE SCRAPBOOK erioperative nurses and SPD professionals from across the country gathered at the Palms Casino Resort in Las Vegas, Nevada for the 2019 OR Today Live Conference from August 18-20. Attendees were able to network in the exhibit hall, exchange ideas during education and earn CE credits. The classes, super sessions and keynote included world-class speakers and provided attendees with invaluable knowledge to take back to their departments. Everyone even had some fun with Elvis and the Rat Pack!

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1. OR Today Live featured a step and repeat for attendees to take pictures.

4. The exhibit hall was full of great products and solutions.

at the “Under the Stars Party� on Monday night.

2. Elvis Presley made an appearance at the conference and enjoyed reading OR Today magazine.

5. Phyliss Quinlan with MFW Consultants spoke on understanding and managing bullying and incivility during one of the super sessions.

7. Relax! You can view the rest of the photo gallery on ortodaylive.com.

3. Attendees won door prizes and other OR Today merchandise through a scavenger hunt.

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6 72 | OR TODAY | OCTOBER 2019

6. Attendees had fun dancing and kicklining

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8. Attendees were seen engaging with vendors in the exhibit hall.

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9. The OR Today Live conference allowed former and new attendees to reconnect and socialize.

10. The Rat Pack interacted with attendees in the Moon lounge of the Palms Resort Casino.

11. Sharon McNamara, Jamie Ridout and William Duffy gave a

great presentation titled “Leadership Across Generations.”

12. Thank you to everyone, especially the attendees, who made the show a success!

13. Jeff Taltavull showed attendees AIV’s products inside the exhibit hall.

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14 WWW.ORTODAY.COM

15. Dean Martin and the Rat Pack serenaded attendees at the “Under the Stars Party,” sponsored

by AIV.

ORTL Scrapbook

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14. David Taylor, Yvette Stanley and Lee Hedman were great additions to the conference.

INDUSTRY INSIGHTS

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15 OCTOBER 2019 | OR TODAY |

73

INDEX

advertisers

ALPHABETICAL Action Products, Inc.……………………………………… 25 AIV Inc.…………………………………………………………………15 ALCO Sales & Service Co.……………………………… 60 AORN………………………………………………………………… 59 AORN of Middle Tennessee…………………………… 48 ASCA………………………………………………………………… 27 Avante Patient Monitoring……………………………… 49 BD……………………………………………………………………… 43 C Change Surgical……………………………………………… 6 Cygnus Medical…………………………………………………… 9

Doctors Depot…………………………………………………… 4 Ecolab Healthcare……………………………………………IBC Healthmark Industries Company, Inc.…… 44-47 Heartland Medical Sales & Service…………………13 Innovative Medical Products………………………… BC Key Surgical……………………………………………………… 10 MAC Medical, Inc……………………………………………… 33 MD Technologies Inc.……………………………………… 54 MedWrench……………………………………………………… 42 Microsystems……………………………………………………… 5

Mobile Instrument Service & Repair………60, 67 OR Today Webinars………………………………………… 63 Pure Processing………………………………………………… 28 Ruhof Corporation……………………………………………2, 3 Soma Technology………………………………………………19 TBJ Incorporated……………………………………………… 64 Tetra Medical Supply Corp.…………………………… 25 TIDI………………………………………………………………… 20, 21

HOSPITAL BEDS/PARTS

Heartland Medical Sales & Service…………………13 Mobile Instrument Service & Repair………60, 67 Soma Technology………………………………………………19

CATEGORICAL ANESTHESIA

Doctors Depot…………………………………………………… 4 Heartland Medical Sales & Service…………………13 Soma Technology………………………………………………19

ALCO Sales & Service Co.……………………………… 60

INFECTION CONTROL

AORN………………………………………………………………… 59 AORN of Middle Tennessee…………………………… 48 ASCA………………………………………………………………… 27

ALCO Sales & Service Co.……………………………… 60 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…… 44-47 Pure Processing………………………………………………… 28 Ruhof Corporation……………………………………………2, 3 TBJ Incorporated……………………………………………… 64 TIDI………………………………………………………………… 20, 21 TIDI………………………………………………………………… 20, 21

C-ARM

INSTRUMENT STORAGE/TRANSPORT

ASSET MANAGEMENT

Microsystems……………………………………………………… 5

ASSOCIATION

Soma Technology………………………………………………19

REPROCESSING STATIONS

Pure Processing………………………………………………… 28 Ruhof Corporation……………………………………………2, 3 TBJ Incorporated……………………………………………… 64

RESPIRATORY

Soma Technology………………………………………………19

SAFETY

Healthmark Industries Company, Inc.…… 44-47 Key Surgical……………………………………………………… 10 TIDI………………………………………………………………… 20, 21

CARDIAC PRODUCTS

C Change Surgical……………………………………………… 6

Cygnus Medical…………………………………………………… 9 Key Surgical……………………………………………………… 10 Ruhof Corporation……………………………………………2, 3 TIDI………………………………………………………………… 20, 21

CARTS/CABINETS

INSTRUMENT TRACKING

Microsystems……………………………………………………… 5

Pure Processing………………………………………………… 28 Ruhof Corporation……………………………………………2, 3 TBJ Incorporated……………………………………………… 64

INVENTORY CONTROL

SKIN PREPARATION

Key Surgical……………………………………………………… 10

BD……………………………………………………………………… 43

MONITORS

STERILIZATION

Avante Patient Monitoring……………………………… 49 Doctors Depot…………………………………………………… 4 Soma Technology………………………………………………19

Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…… 44-47 TBJ Incorporated……………………………………………… 64

ONLINE RESOURCE

SURGICAL

ALCO Sales & Service Co.……………………………… 60 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…… 44-47 MAC Medical, Inc……………………………………………… 33 TBJ Incorporated……………………………………………… 64

CS/SPD

MD Technologies Inc.……………………………………… 54 Microsystems……………………………………………………… 5 Ruhof Corporation……………………………………………2, 3

DISINFECTION

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

MedWrench……………………………………………………… 42 MedWrench……………………………………………………… 42 OR Today Webinars………………………………………… 63

DISPOSABLES

OR TABLES/BOOMS/ACCESSORIES

ALCO Sales & Service Co.……………………………… 60 Tetra Medical Supply Corp.…………………………… 25

ENDOSCOPY

Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…… 44-47 MD Technologies Inc.……………………………………… 54 Mobile Instrument Service & Repair………60, 67 Ruhof Corporation……………………………………………2, 3

ERGONOMIC SOLUTIONS

Pure Processing………………………………………………… 28

FALL PREVENTION

ALCO Sales & Service Co.……………………………… 60

FLUID MANAGEMENT

Ecolab Healthcare……………………………………………IBC MD Technologies Inc.……………………………………… 54

GENERAL

AIV Inc.…………………………………………………………………15

74 | OR TODAY | OCTOBER 2019

Action Products, Inc.……………………………………… 25 Innovative Medical Products………………………… BC Soma Technology………………………………………………19

PATIENT DATA MANAGEMENT

MAC Medical, Inc……………………………………………… 33

PATIENT MONITORING

AIV Inc.…………………………………………………………………15 Avante Patient Monitoring……………………………… 49 Heartland Medical Sales & Service…………………13

POSITIONING PRODUCTS

SINKS

Heartland Medical Sales & Service…………………13 MD Technologies Inc.……………………………………… 54 Soma Technology………………………………………………19 TIDI………………………………………………………………… 20, 21

SURGICAL INSTRUMENT/ACCESSORIES

C Change Surgical……………………………………………… 6 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…… 44-47 Key Surgical……………………………………………………… 10

TELEMETRY

AIV Inc.…………………………………………………………………15 Avante Patient Monitoring……………………………… 49

TEMPERATURE MANAGEMENT

C Change Surgical……………………………………………… 6 MAC Medical, Inc……………………………………………… 33

Action Products, Inc.……………………………………… 25 Cygnus Medical…………………………………………………… 9 Innovative Medical Products………………………… BC

WARMERS

PRESSURE ULCER MANAGEMENT

WASTE MANAGEMENT

Action Products, Inc.……………………………………… 25

REPAIR SERVICES

Avante Patient Monitoring……………………………… 49 Cygnus Medical…………………………………………………… 9 Doctors Depot…………………………………………………… 4

MAC Medical, Inc……………………………………………… 33 MD Technologies Inc.……………………………………… 54 TBJ Incorporated……………………………………………… 64

WOUND MANAGEMENT

Tetra Medical Supply Corp.…………………………… 25

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