OR Today - December 2019

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contents features

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LET IT FLOW: EFFICIENT TRANSITIONS ELEVATE CARE Perioperative services is one of the most interconnected units in a hospital, so inefficient flow of patients through the perioperative area can cause disruptions that ripple throughout the entire organization. In this article, experts share tips on how to streamline the process.

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Waste that is generated during surgical

The U.S. is in the middle of an opioid epidemic related to the overprescribing of painkillers. The goal of this continuing education program is to enhance the ability of nurses to identify and respond professionally to drug-seeking patients.

MARKET ANALYSIS

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CORPORATE PROFILE: MD TECHNOLOGIES

15% is hazardous. The global medical waste

MD Technologies Inc. has provided costsavings to health care facilities for decades.

In this article, MD Technologies Inc. President William L. “Bill” Merkle shares more information about his company and the cost-savings products it supplies to health

management market is projected to reach

care facilities.

processes is known as surgical waste.

Surgical waste is both hazardous and nonhazardous. Out of the waste generated from surgeries, 85% is non-hazardous and

$18 billion by 2024.

OR Today (Vol. 19, Issue #12) December 2019 is published monthly by MD Publishing, 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290. POSTMASTER: Send address changes to OR Today at 1015 Tyrone Rd., 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. © 2019

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ART DEPARTMENT Jonathan Riley Karlee Gower Amanda Purser

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CIRCULATION

INDUSTRY INSIGHTS 10 News & Notes 14 CCI: BSN Level Education in the Perioperative Nursing Workforce 16 Going digital: Using real data to prevent infection 18 IAHCSMM: AORN Updates Guideline on Sterilization Packaging 20 OR Today Webinar Series Breaks All-time Record for Largest Webinar 22 ASCA: ASCs Embrace Nation’s Renewed Focus on Healthcare Quality 25 Doctors Depot’s Frye and Son Support Bahamas Relief 26 Moving Beyond Wellness Programs: Three Steps to Addressing Employee Burnout at Health Systems

Lisa Cover

WEBINARS Linda Hasluem

ACCOUNTING Diane Costea

IN THE OR 29 Market Analysis: Reports Forecast Medical Waste Market Growth 30 Product Focus: Waste Management 32 CE Article: Recognizing Drug-Seeking Behavior

OUT OF THE OR 48 Spotlight On 50 Fitness 52 EQ Factor 54 Health 56 Nutrition 58 Recipe 60 Pinboard

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INDUSTRY INSIGHTS

news & notes

AORN, CCI to Boost Educational and Certification Opportunities The Association of periOperative Registered Nurses (AORN) and the Competency and Credentialing Institute (CCI) have announced a new partnership to develop improved educational and certification opportunities to support the career development of perioperative nurses.

The organizations share a commitment to lifelong learning and professional development for the nurses who work in the pre-, intra- and post-operative care of surgical patients and the belief that quality education provides the foundation for safe patient care.

In 2020, AORN and CCI will present new educational offerings and resources aligned to better assist individuals and facilities to take advantage of certifications and additional pathways to certification.

AORN was established in 1949 as a membership association. Today, the organization unites and empowers perioperative nurses, healthcare organizations, and industry partners to support safe surgery for every patient, every time. AORN resources are used in every hospital and ambulatory center across the country, including the evidencebased Guidelines for Perioperative Practice, perioperative staff education, leadership development, career guidance, and facility and health system solutions.

“At AORN, our goal is to support a perioperative nursing workforce that is engaged in lifelong learning. For all the nursing challenges that health care transformation present, it offers just as many opportunities,” said AORN CEO/Executive Director Linda Groah, MSN, RN, CNOR, NEA-BC,

10 | OR TODAY | DECEMBER 2019

FAAN. “But those opportunities are only available to the nurses who are prepared to take advantage of them. This partnership with CCI will enable perioperative nurses in hospitals and ambulatory surgery centers to perform at the highest level of competency.”

CCI is a leader in credentialing, nursing competency assessment and education for the perioperative nursing community. For more than 35 years, CCI has administered the CNOR credentialing program, and now also administers the CSSM and CNS-CP credentialing programs. The company currently certifies more than 40,000 nurses.

“Perioperative nursing is a demanding, technologyintensive specialty with a rapid pace of change. Certification programs such as the CNOR credential validate the knowledge needed to practice in the specialty. The recertification processes for the CNOR credential facilitate lifelong learning designed to enhance the competency of a perioperative nurse practicing in a variety of perioperative roles,” said James Stobinski, PhD, RN, CNOR, president of CCI. AORN and CCI partnered to create the Professional Educator, Perioperative Certificate of Mastery (PEP COM) Pre-Conference Program which has been updated by CCI for presentation as a workshop on March 27, 2020, one day prior to the start of the AORN Global Surgical Conference & Expo in Anaheim, CA. This workshop will provide new and seasoned educators the knowledge and tools needed to provide exceptional orientation and professional development opportunities for the entire perioperative team. •

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INDUSTRY INSIGHTS

news & notes

Healthmark Introduces Two New Cleaning Brushes Healthmark Industries announced the addition of two new brushes to the ProSys Instrument Care product line.

Designed for cleaning instruments prior to further processing, these reusable brushes are manufactured with nylon bristles that adhere to a contoured plastic handle.

These brushes are used in conjunction with a suitable cleaning solution that assist health care workers in the

initial cleaning of items for which brushing to remove contamination is a recommended step in the cleaning process. The “3183-P” is available for purchase in a package of 10 and the “MR001903” is available in a package of 3. • For more information, visit www.hmark.com.

Sterilucent Announces Clearance To Market New Low-Temperature Sterilization System Sterilucent Inc. has received regulatory clearance to market the Sterilucent HC 80TT Vaporized Hydrogen Peroxide Sterilizer with Cycle Guardian technology in the United States.

Cycle Guardian technology includes advanced and continuous critical parameter monitoring capability, which enables advanced dynamic sterilant delivery, confirms that the minimum required concentration of the sterilant is maintained and optimizes the sterilant for each specific load in the chamber. It includes enhanced and customized drying capability that results in fewer aborted cycles as well as cycle-specific biological process challenge devices that provide appropriate independent validation of each sterilization cycle of the sterilizer.

This new tabletop unit addresses troublesome challenges that can affect productivity, sterility assurance and drying efficacy when using this type of sterilization process.

“We are very excited to be offering health care providers several valuable innovations for their low-temperature sterilization needs,” said Chief Operating Officer Stephen Loes. “The HC 80TT sterilizer is capable of delivering real improvements in productivity and cost reduction,

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and offers functions and accessories designed to improve users’ confidence in the sterilization process. Moreover, early testing indicates that our dynamic sterilant delivery system helps prolong the useful life of moisture and heatsensitive reusable devices.”

The Sterilucent HC 80TT sterilizer offers additional features/technologies that help reprocessing departments save cost and improve throughput, including a large capacity 83-liter chamber that accommodates a maximum load of 14.5 kg (31.9 lbs.) and allows more instruments to be processed per cycle. It has the capability to reprocess two flexible scopes in a single Flexible Cycle.

Hospital sterile processing departments, outpatient centers and endoscopy suites will gain additional benefits from the HC 80TT sterilizer’s user-centric design. For example, the system is easy to load and has an intuitive touch-panel interface. An optional user tracking feature is available, facilitated by easy barcode data entry. All in all, the HC 80TT VHP sterilizer brings a new level of process assurance, reprocessing productivity and user convenience to low-temperature reprocessing. • For more information, visit sterilucent.com.

DECEMBER 2019 | OR TODAY |

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INDUSTRY INSIGHTS

news & notes

Key Surgical Awarded Group Purchasing Agreement Key Surgical has been awarded a group purchasing agreement with Premier. The new agreement allows Premier members, at their discretion, to take advantage of special pricing and terms pre-negotiated by Premier for instrument cleaners and enzymatics.

“Key Surgical is thrilled to extend our relationship with Premier,” says Erik Hromatka, director, national accounts, Key Surgical. “We are proud to supply products and education to sterile processing that help improve patient safety through excellence in cleaning and sterilization. This agreement with Premier provides members access the tools and support needed and now will allow ASCEND members to do so while they continue their commitment to the Premier ASCEND program.”

Products in the agreements include: • Instrument Cleaning Brushes • Dr. Weigert neodisher MultiZym • Dr. Wegiert neodisher PreStop • Instrument Tip Caps • Duraholder IPS • Instrument Sleeves • Instrument Identification Tape • Acetabular Reamer Brushes • Scope Cleaning Brushes • Toothbrush-Style Cleaning Brushes

12 | OR TODAY | DECEMBER 2019

Hospital Implements Smart Pump Programming with Medfusion 4000 Wireless Syringe Pump Smiths Medical, a global medical device manufacturer, announced its go-live of smart pump programming of the Medfusion 4000 wireless syringe infusion pumps from HCA’s electronic medical records system (EMR) at Chippenham & Johnston-Willis Hospitals. They are the first in the “HCA Healthcare Capital Division” to transition to smart pump programming.

Smart pump programming will allow clinician order parameters to be sent to the pump ensuring the prescribed medication, concentration, rate and dose is delivered to the patient. This increases patient safety by minimizing possible programming errors.

Smart pump programming is supported by Integrating the Healthcare Enterprise (IHE), an initiative by health care professionals and industry to improve the way computer systems in health care share information. IHE promotes the coordinated use of established standards such as DICOM and HL7 to address specific clinical needs in support of optimal patient care. Systems developed in accordance with IHE communicate with one another better, are easier to implement and enable care providers to use information more effectively. • For more information, visit smiths-medical.com.

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AAAHC Report Identifies Areas of Compliance, Opportunities for Improvement AAAHC recently released its Quality Roadmap 2019 report, which includes analyses of data from more than 1,200 accreditation surveys conducted in 2018. The report identifies areas of high and low compliance, providing expert insight into how ambulatory health care organizations can improve their performance and quality of care. The most common deficiencies centered on quality improvement studies, infection prevention/safe injection practices, credentialing and privileging, as well as documentation management.

“We designed the Quality Roadmap to help organizations identify themes that deserve special attention when pursuing ongoing quality improvement throughout the accreditation cycle,” said Noel Adachi, president and CEO of AAAHC. “Using this report, along with our growing portfolio of educational programs and resources, organizations can integrate best practices to help them excel through all 1,095 days of an accreditation term.”

The AAAHC Quality Roadmap 2019 examined organizations’ compliance ratings for current AAAHC Standards during 1,299 onsite surveys from March 1–December 31, 2018. The types of organizations surveyed include ambulatory surgery centers (ASC), office-based surgery practices (OBS) and primary care (PC) settings.

The report indicates that the top deficiencies cited in more than 10 percent of survey ratings were consistent with themes identified in the 2018 results, including quality improvement studies, credentialing and privileging, documentation, and safe injection practices.

AAAHC’s analysis also found accredited organizations have shown improvement in key areas broken down by Non-Medicare and Medicare Deemed Status Standards.

“The Quality Roadmap presents actionable data that can be used to help ambulatory providers develop stronger policies, procedures and practices. These, in turn, will help to build a quality improvement culture that is integrated into day-to-day operations, building off the 1095 Strong, quality every day philosophy,” said Naomi Kuznets, Ph.D., AAAHC Institute vice president and senior director. “Organizations are encouraged to share and discuss the report’s findings with their teams to drive collaboration and decision making focused on quality improvement and other corrective actions.”

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13

INDUSTRY INSIGHTS CCI

BSN Level Education in the Perioperative Nursing Workforce

By Jim Stobinski n October of 2019 the Competency and Credentialing Institute (CCI) published a position paper titled, “The BSN-Educated Nursing Workforce.” The paper is available for download from the CCI website. Much has been written about BSN level education for the nursing profession and the subject continues to generate considerable discussion and disagreement among nurses. The impetus for this paper was twofold. The first prompt was the recent discussion at the AORN Surgical Conference and Expo on this subject and the second was legislation enacted in the state of New York regarding educational preparation for nurses – The BSN in 10 law.

I

Although CCI staff frequently publish peer-reviewed literature and make presentations, the organization had not previously published a position paper.

As the CEO of CCI, I expect this paper will prompt further comment and perhaps elicit strong reactions from some nurses. In this column, I would like to expand on the material presented in the paper and provide further context. First, the CCI does not take a stance on educational preparation to enter the profession. It has long been established that all three current educational paths (Diploma, AD and BSN) produce well-prepared clinicians. The Associate Degree as an entry point to the nursing profession

14 | OR TODAY | DECEMBER 2019

is essential to meet the demand for nursing care. Setting aside the question of pre-licensure education choice, the issue for CCI then becomes – What is the level of education needed by nurses for the care to be provided in the future?

The profession of nursing is conducted in an increasingly complex, technology-rich environment with a rapid rate of change. The body of research-based evidence strongly supports that improved patient outcomes and financial results correlate with a greater ratio of care delivered by BSN prepared nurses. Although earlier, less complex studies conducted 15+ years ago produced equivocal results in this area that is no longer the case. Recent studies using advanced statistical measures now provide clear, unequivocal evidence supporting BSN level education for nurses. In short, the train has left the station on this matter and as a profession nursing should respond to the evidence.

The CCI is familiar with the body of evidence cited in the preceding paragraph and we felt compelled to state our position on the issue. I have witnessed the strongly worded statements by nurses who cite the work of exemplary nurses educated at the AD level and also the shortfalls of BSN educated nurses. As an organization, CCI maintains that these anecdotes, however convincing and strongly felt, constitute a low level of evidence. We believe it is time to act on the wealth of convincing research now in the field and work to increase the ratio of care

provided by BSN-prepared nurses.

CCI believes that the stakeholders in nursing should collaborate to develop programs to facilitate the transition to BSN level education. The wealth of BSN completion programs now makes this task easier. CCI demonstrates their support for BSN level education with policies that support this progression to include our recertification processes. We also support research, through the CCI Research Foundation, that adds to the evidence in this area. As an organization CCI strives to be a thought leader for the profession, particularly so about credentialing.

We are grateful for the opportunity provided by this column to share our thoughts and further the discussion of these important topics. You can expect further position papers from CCI on matters such as Continuous Professional Development (CPD) and educational standards for nurses.

James Stobinski, PhD, RN, CNOR, CSSM (E), has in excess of 30 years experience in the operating room. He has 18 years of management experience in perioperative nursing and has published and presented extensively at the national level on perioperative management related topics. He also serves as adjunct faculty at Nova Southeastern University in Ft. Lauderdale, Florida and Wilkes University in Pennsylvania. In February 2017, he began serving as the CEO of the Competency and Credentialing Institute. He maintains an active research agenda centered on nursing workforce issues and certification.

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Programmatic Approach to OR Cleaning and Turnover Digital Analytics and Actionable Insights

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INDUSTRY INSIGHTS Ecolab

Going digital: Using real data to prevent infection

By Dustin Rahlf, Director of Healthcare Digital Solutions at Ecolab hile AI & robot enabled surgeries are capturing headlines, real-time digital dashboards and predictive analytics may be the overshadowed sidekick that enables a safer operating room (OR).

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It is widely known that previously contaminated OR environments have an increased transmission risk of pathogens that cause healthcare-associated infections (HAIs).1 However, HAIs - though largely preventable - continue to put patients at risk and cost hospitals thousands of dollars every year. Consider this: One out of every 31 hospitalized patients will contract at least one HAI, resulting in roughly 75,000 deaths each year in the U.S.2 That’s more deaths than those caused by automobile accidents.3 Even if the infections don’t result in death, the extended-stay for additional treatment can cost hospitals upwards of $20,000 per patient.4 Improved cleaning can decrease this risk, yet just 25% of critical high-touch surfaces in the OR are adequately cleaned.5,6 While ORs may dedicate more time to cleaning in order to reduce contamination, there is, in fact, little correlation between the time spent cleaning and actual cleaning effectiveness.7 This

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suggests there is a fundamental lack of process control during cleaning, which contributes to ineffective environmental cleaning in the OR, high turnover time, practice variations and HAIs. How can a hospital take action to prevent undue infection? Many use audits and direct observation to evaluate compliance with current cleaning and hand hygiene protocols. However, audits only capture a snapshot in time, providing incomplete data. Direct observation can also be unreliable, in part due to the Hawthorne effect: when people are aware they are under observation, they modify their behavior.

A more dynamic, objective and effective approach is to use digitally enabled programs that allow for consistent, accurate monitoring. This monitoring produces real-time data points that feed into digital dashboards, which – through both real-time, actionable data and predictive analytics – allow healthcare systems to objectively monitor cleaning effectiveness, streamline workflows and prevent the spread of pathogens that lead to infection.

Accessing real-time data Monitoring cleaning and disinfection activity as it happens is a vital first step in reducing the number of HAIs. A fully integrated digital dashboard system enables

turnover teams and managers to track high-touch object (HTO) cleanliness and room turnover time in operating rooms.

These dashboards extend to other parts of the hospital as well, including surgical instrument cleanliness in the central sterile department, cleaning thoroughness in patient rooms and hand hygiene compliance for staff, all in one place. Having the information available in real-time allows for immediate intervention, which can stave off the spread of infection once the risk is detected.

The ability to intervene is particularly important in the OR, where patients may be undergoing invasive surgery and are particularly susceptible to infection. There is a continuous flow of pathogens from infected or colonized patients to the hands of healthcare workers to environmental surfaces and then back to patients. The intervention allows hospitals to break the chain of infection. Studies have concluded that the OR should follow enhanced cleaning protocols based on the higher levels of contamination found on high-touch surface areas compared to other, lowertouch surface areas within a hospital.8

Contaminated surfaces and suboptimal cleaning processes create an environment that is more susceptible to the transmission of pathogens that can lead to HAIs.9 Real-time reporting helps WWW.ORTODAY.COM

monitor progress and provides assurance that equipment, instruments and rooms are clean and safe. It can also enhance operational efficiencies and drive increased productivity and patient flow.

Ensuring all equipment and surfaces are sufficiently clean can reduce the cost and complications associated with HAIs, enabling hospitals to admit and treat more patients during the year. That’s important for generating more revenue.

Using data to make a change Tracking the data is only part of the equation. Acting on it is what leads to real change. Digital dashboards translate data into easy-to-read, actionable reports at the system, hospital, unit, individual and even object level. Hospitals receive alerts when issues or inefficiencies arise, allowing them to immediately pinpoint the area (or areas) where corrective action is needed.

A hospital in Pittsburgh that performs more than 23,000 surgeries each year implemented the Ecolab OR Program, which includes digital dashboards. Before the program started, the hospital was cleaning just 20% of HTOs in between-case turnovers, and it was taking teams 30 minutes for each turnover. Over two months, dashboards tracked cleaning thoroughness of HTOs, allowing OR leadership to identify teams, individuals and objects that needed attention so they could take targeted corrective action. The insights derived from the dashboard enabled this hospital to improve HTO cleaning by 66% and decrease OR turnover time by an average of 21 minutes, resulting in a savings of approximately $800 per room.10 Having immediate access to this data enables hospitals to objectively assess workflows and processes across an entire healthcare system to drive consistency and standardization while actively optimizing performance and controlling costs.

Turning data into predictive insights As technology improves, healthcare systems will increasingly have the ability to extrapolate collected data, allowing them to move beyond reacting to infection risk, to predicting and preventing the spread of infection in the first place.

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By analyzing current and historical data within the dashboards, hospitals can detect patterns, assess trends and identify correlations that may not have been as obvious through direct observation or audits. The comprehensive insights gained can facilitate quick decision-making in critical situations and contribute to strategic planning, setting hospitals up for continued improvement.

The most sophisticated digital dashboards can also generate customized reports that give hospitals the capability to set goals and benchmark internally or against industry averages. A customized report for the OR can track the thoroughness of cleaning, room turnover time and adherence to the Association of periOperative Registered Nurses (AORN) guidelines over time.

The dashboards also produce scorecards, allowing hospitals to track progress against established target metrics to evaluate how effective they are from the facility level down to an individual.

Tracking patterns and putting corrective measures in place allows a hospital to predict incidents before they happen, mitigating risk to patients, staff and hospital.

Looking ahead, the potential to pair information gained from digital dashboards with information from electronic health records (EHRs) may someday offer a powerful opportunity to minimize patient risk further. The collective insights from combining the hospital environment and staff data with individual patient risk data would help eliminate surprises and enable hospitals to put proactive measures in place so staff could intervene where necessary.

For example, EHRs could help identify patients who are at higher risk of infection or have unique needs, and staff would reference the digital dashboards to ensure the quality of the patient interactions and the cleanliness of the environment met the patient’s needs to provide the best possible outcome.

Having access to real-time data and monitoring patterns enables clinicians to interrupt the chain of infection transmission, mitigating the risk of HAIs. When hospitals can tackle issues immediately and have the tools to predict and prevent the spread of infection, they can have the confidence to promote cleaner

INDUSTRY INSIGHTS Ecolab

and safer environments. Encourage your facility to look into modernizing its infection prevention strategy by learning more about digitally enabled programs.

REFERENCES: Cohen B, Cohen C C, Løyland B, and Larson E L. Transmission of health care-associated infections from roommates and prior room occupants: a systematic review.

Clinical Epidemiology 2017;9: 297-310.

2 HAI Data and Statistics. Centers for Disease Control and Prevention. https://www.cdc.gov/hai/ surveillance/index.html Accessed 3/27/2019.

3 Rau, J. Hospital infections kill more people than car crashes. Here’s how to cover them better.

Columbia Journal Review. Oct. 2014. http:// archives.cjr.org/the_second_opinion/how_to_use_ the_hospital_infections_database.php 4 Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW. Health Care-Associated Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Intern Med. 2013;173(22):2039-2046. doi:10.1001/jamainternmed.2013.9763.

5 Link T, Kleiner C, Mancuso M et al. Determining high touch areas in the operating room with levels of contamination. Am J Infect Control.

2016 Nov 1;44(11):1350-1355.

6 Yezli S, Barbut F and Otter JA. Surface contamination in operating rooms: A risk for transmission of pathogens? Surg Infect (Larchmt). 2014 Dec;15(6):694-9.

7 Datta R, Platt R, Yokoe DS, Huang SS. Arch Intern Med. 171:6, Mar 28, 2011 8 Slide courtesy of Dr. Philip Carling, Boston University School of Medicine, 2012 9 Rupp ME, Adler A, Schellen M, Abstract 203 Fifth Decennial, Slide courtesy of Dr. Philip Carling, BU School of Medicine 10 Kramer M and Kriznik S. The impact of an OR environmental hygiene program on OR culture and cleanliness.

OR Manager Conference; Las Vegas, NV; Oct. 21-23, 2016.

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INDUSTRY INSIGHTS

IAHCSMM

AORN Updates Guideline on Sterilization Packaging

By Susan Klacik

he primary objective of sterilization packaging is to maintain the sterile integrity of the packaged contents until they are used. Many factors influence this outcome and the Association of periOperative Registered Nurses’ (AORN’s) newly updated “Guideline for Sterilization Packaging Systems” addresses all the activities related to sterilization packaging.

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AORN assessed peer-reviewed literature published in English from January 2013 until December 2018. The articles were evaluated and appraised for the quality of the evidence. Through this rigorous review, the AORN’s “Guideline on Sterilization Packaging Systems” was updated. This article will highlight some of the key changes to this guideline.

Packaging begins with the prepurchase evaluation of a packaging system. The guideline provides a listing of considerations such as: • Product quality assurance testing results; • Compatibility with the intended sterilization method(s) and cycles used within the facility; • Requirements for cleaning according to the instructions for use (IFU) (e.g., laundry for textiles, equipment for cleaning rigid containers); • Requirements for tracking use; and • Method for tracking use.

The previous version of the guideline contained a statement regarding the environmental consideration of packaging systems. Being a patient advocate is not limited to just the surgical procedure; human health also depends upon the environment and it is important that the environment is protected. The new guideline recommends selecting an environmentally

18 | OR TODAY | DECEMBER 2019

preferable sterilization packaging system, if the systems are equivalent in performance.

Continuing the environmental sustainability theme is the criteria for evaluating the sterilization packaging for the environmental impact (this includes the packaging reusability and disposal).

Compatibility with a sterilization process is always a consideration. This updated guideline includes the packaging for sterilization using hydrogenperoxide combined with ozone, which has recently been introduced in the U.S.

Preparation and packaging The updated guideline recommends that packaging for sterilization be performed in an area intended, designed and equipped for sterilization packaging activities, such as the packaging area of the sterile processing department (SPD). Users are advised to verify that instruments and other medical devices have been cleaned, inspected and assembled according to the manufacturer’s IFU prior to packaging.

The use of colored or tinted tip protectors is recommended for sharp items to protect instrumentation from damage and to protect personnel.

Colored or tinted tip protectors make

it easier for personnel to see, which is important on a sterile field. Clear tip protectors are difficult to see and can pose a risk for a retained surgical item.

As instrumentation is handled during preparation, there is a concern of transferring what is on the hands of the assembler to the instrumentation. Research has shown that contaminants, oils and soils transferred to instruments from the hands of personnel can compromise sterilization. This research resulted in recommending that personnel who perform inspection, assembly and packaging of reusable surgical instruments perform hand hygiene within the hour or wear clean gloves to perform these tasks.

AORN recommends performing hand hygiene before handling instruments and medical devices for sterilization.

The practice of packaging loaned instrumentation is also addressed in the guideline. AORN recommends obtaining the sterilization packaging information for loaned instrument sets from the vendor that provides the instrumentation.

Research shows benefits of standardizing sterilization packaging processes in regard to efficiency and the prevention of errors (e.g., missing or wrong items in a set). Organizing accessories can help users implement standardized procedures.

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Count sheets, shelf life and packaging integrity Some facilities struggle with how to include count sheets in a package and this, too, is addressed in the guideline.

Each health care organization will need to determine if count sheets may be placed in trays. During this review, it is important to consider the limited research regarding the safety of subjecting toners, inks and various papers to any sterilization method. Chemicals used in the manufacturing of paper, toners and inks pose a theoretical risk of reaction in some sensitized individuals. One research study concluded that the label and toner ink transferred during sterilization was not cytotoxic; however, further study is needed to incorporate a larger sample, various sterilization methods, and instruments of a variety of compositions.

The shelf life of sterile packages is no longer included in the “Guideline on Sterilization Packaging Systems,” since it is included in the “Guideline for Sterilization,” which still supports event-related sterility.

Checking IFU for the products used for sterilization is a key principal of sterilization and packaging. The updated guideline now includes what to look for in the IFU when selecting a singleuse, nonwoven sterilization wrapper.

Not all single-use, nonwoven packaging systems are validated for all sterilization methods and cycles. In addition, the IFU can provide information for the correct use and maintenance.

Holes in a wrapper can allow microbes to enter a sterilized pack-

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age and contaminate it. To prevent holes from occurring, the guideline includes the use of corner protectors for wrapped trays. The guideline reminds the reader to check the IFU of the corner protector manufacturer for information regarding the type of validated sterilization method.

Recommendations for the placement of peel packaging in the sterilizer has been removed from the guideline.

Users should follow guidance from the manufacturer’s IFU for specific instructions on loading the sterilizer.

There are two new recommendations for rigid containers. It is now recommended that users establish and implement a schedule for routine rigid sterilization container inspection, maintenance and repair. Also, new factors have been added regarding what to look for in the container’s IFU that provides information on their correct use. The following is a brief example: • Instructions for inspection and routine maintenance; • Recommended types and placement of instruments and other medical devices; and • The most challenging location within the package for placement of internal chemical indicators (CIs) and internal biological indicators (BIs).

The complete guideline is available for purchase on the AORN website at www.aorn.org.

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

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INDUSTRY INSIGHTS

WEBINAR SERIES

webinar

OR Today Webinar Series Breaks All-time Record for Largest Webinar

By Erin Register R Today experienced another record-breaking week of attendance, setting the new highs even higher! The September 26 webinar, sponsored

by Ruhof, surpassed the previous record-breaking webinar, sponsored by Healthmark.

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The webinar “Care, Handling, Inspection and Prevention for GI Endoscopy Professionals” was presented by Lawrence F. Muscarella, Ph.D., independent consultant, and Ron Banach, director of clinical training, Ruhof Corporation, and sponsored

by Ruhof. The session drew 505 attendees, with 907 total registrants, for the live presentation. It set new records with the most registrations and attendees since the series began in 2014! Attendees gave the webinar a rating of 4.1 on a 5-point scale.

The 60-minute webinar, presented by Muscarella and Banach, discussed a Care, Handling, Inspection and Prevention (CHIP) program for GI endoscopy professionals. The webinar increased awareness about the risk of GI endoscopes transmitting multidrug-resistant bacteria. They also discussed some “best practices” for the care of handling GI endoscopes, as well as provided solutions to some endoscope reprocessing problems. They went on to stress the importance of a GI endoscopy department’s adherence to standards, guidelines and device instructions for use (IFU). Lastly, they provided recommendations to improve safety in the GI endoscopy unit.

Attendees provided positive feedback via a post-webinar survey.

“A lot of information in a short amount of time! Excellent for those of us with busy schedules,” RN Manager J. Walters said.

“Presenters extremely knowledgeable ... loved the examples sprinkled in during webinar; makes it easier to apply to practice,” Infection Preventionist E. Sasser shared.

“This webinar was excellent! It provided detailed information on the care, cleaning and processing of endoscopes! Very informative! Thank you for sharing,” Director of Surgical Services S. Hock stated.

20 | OR TODAY | DECEMBER 2019

“ Extremely important webinar; good review and wake-up call for all staff; we must be the guardians, and this helped refresh on content.”

–L . Smith-Zuba, Director of Perioperative Services “This webinar could not have come at a better time. I am in the process of tracing all of my facilities endoscopes and upon reviewing our procedures and the manufacturer’s IFU, I had many questions that were answered in this very informative webinar.” Infection Preventionist L. Farabaugh said.

“Extremely important webinar; good review and wake-up call for all staff; we must be the guardians, and this helped refresh on content,” Director of Perioperative Services L. Smith-Zuba stated.

“OR Today’s Webinar Series is always very informative and professionally prepared. The speakers are knowledgeable about the topics and have relevant slides to highlight their material. I recommend OR Today’s Webinars to my colleagues at AORN meetings,” stated G. Harman, Director of Perioperative Nursing Services.

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.

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INDUSTRY INSIGHTS ASCA

ASCs Embrace Nation’s Renewed Focus on Healthcare Quality

By Bill Prentice s the Democratic presidential candidates continue to define their plans for delivering affordable, accessible healthcare and members of Congress on both sides of the aisle continue to explore ways to cut the cost of that care without sacrificing quality, ways of assessing and reporting healthcare quality continue to make headline news.

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President Donald Trump intensified the focus on quality data collection and use back in June when he issued an executive order calling for creation of a “Health Quality Roadmap” and a set of reforms intended to make more meaningful price and quality information more broadly available to more Americans. His intent, according to the order, is “to enhance the ability of patients to choose the healthcare that is best for them.”

ASCs have long shared this goal and are continuing to do their part to refine existing programs and test new tools and techniques that can lead to greater success. One example of the work being done is the sixth annual conference of the ASC Quality Collaboration that convened in Washington, DC, this summer.

This meeting brings together a wideranging group of stakeholders that, this year, included ASC owners and operators, health information technology vendors, physicians and representatives of several federal regulatory agencies, accreditation

22 | OR TODAY | DECEMBER 2019

organizations and quality groups. The diversity of the group and the willingness of so many to return year after year to report on the progress they have made and learn from what others have achieved is testament to the ASC community’s ongoing commitment to improving the quality of care ASCs provide.

Important updates delivered at this year’s meeting include the following: A status report on the Centers for Medicare & Medicaid Services (CMS) Outpatient and Ambulatory Surgery Survey Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey indicated that, in response to concerns expressed by the ASC community, the agency is conducting a survey mode experiment for the survey. Until this test, which incorporates an electronic version of the survey, is complete and the results evaluated, the survey will not be made mandatory in the ASC space.

Missy Danforth, vice president of Health Care Ratings at the Leapfrog Group, reported that the organization’s new ASC survey on patient safety and quality is proceeding as planned and is on pace to involve more than 250, and as many as 500, ASCs this year. She indicated that results for individual facilities that participated in the 2019 survey will not be made public and pointed to the value of the survey results in internal, facility-level benchmarking, value-based purchasing and quality improvement. At this time, she added, Leapfrog plans to

publish results publicly for the first time in 2020 and has no plans at this time to assign letter grades to ASCs that participate in the survey as it has done for hospitals that participated in its original survey in the past. For more information on the Leapfrog Group’s ASC Survey, read a Q&A with ASCA Chief Executive Officer Bill Prentice.

Dan Pollock, MD, surveillance branch chief for the Centers for Disease Control and Prevention’s (CDC) Division of Healthcare Quality Promotion (DHQP) presented on the new CDC protocols regarding surveillance for surgical site infections (SSI). In January 2019, the CDC issued new guidance for ASCs that moved SSI surveillance under the Outpatient Procedure Component (OPC) of the National Health Safety Network (NHSN). SSIs account for an estimated annual cost of $3.3 billion and 1 million additional inpatient days, according to the CDC. A handful of states—Colorado, Nevada, New Hampshire, New Jersey and Texas—currently require SSI reporting. These states must report data manually via the NHSN web portal, but Pollock mentioned that CDC hopes to move to electronic health record (EHR) upload reporting if health IT continues to expand in the ASC space.

Some of the current challenges to meaningful quality data collection that meeting participants identified included: • reducing the reporting burden ASCs face while the amount of data being

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collected continues to grow • combatting survey fatigue as increasing numbers of product and service providers continue to institute surveys of every kind • equalizing reporting requirements for the providers of comparable services • defining the most important, most useful measures • collecting survey responses from patients Much work remains before anyone will know for certain what changes President Trump’s executive order will incite or which presidential candidate’s healthcare proposals will be adopted.

Meanwhile, ASCs will continue the work they started decades ago, working inside their own facilities, with nationally recognized researchers and on Capitol Hill, to support all outpatient surgery providers in collecting relevant data and delivering user-friendly reports that give consumers the information they need to make meaningful comparisons and wise choices about where to obtain the healthcare they need.

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WEBINAR SERIES

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INDUSTRY INSIGHTS Doctor's Depot

Doctors Depot’s Frye and Son Support Bahamas Relief

By Erin Register he Bahamas took a devastating hit from Hurricane Dorian over Labor Day weekend this year. Several families lost everything they had; this destruction was especially noticed by Cade Frye, an 11-yearold resident of Jupiter, Florida.

Cade is the son of Doctors Depot’s President Aaron Frye.

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“When Dorian was sitting over the Abacos, my parents were really upset,” Cade explained. “They seemed to know how bad it was going to be before all the news came out. Listening to my parents discuss their plans of how they were going to help with taking over food, water, supplies, etc., I thought of all the kids I’ve become friends with over the years travelling in these exact areas of the Bahamas.”

Cade recalled blurting out, “I want to help the kids,” which became the inspiration for “Backpacks for the Bahamas,” a Facebook group created by Cade as a hurricane relief project.

“I had an idea of a backpack, not for school supplies, but for several items to be packed for that person. The backpack would be easy to carry and ensure that kids would get those items,” Cade said.

The backpacks are filled with essential

Bahama locals with their new backpacks.

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supplies, as well as toys for the children on the island. The Facebook group currently has over 2,000 members, and over 1,000 backpacks have been collected with even more coming in.

When asked for his favorite memory or moment from this experience so far, Cade replied, “Definitely the delivering part.”

“Part of what makes our relief effort awesome is we have taken on the task of personally delivering as many backpacks as possible directly into the hands of the children. We do not want them to go into warehouses and just hope for them to reach the kids. The boys give me high fives and hugs, and it feels awesome! Because we have received so many packs, we have started to use people we trust to deliver the packs to many other islands,” Cade explains. Cade also mentioned how one of the biggest challenges is inspecting every backpack he receives to make sure they are safe and filled with great items.

“We won’t allow the possibility of one child getting a great backpack full of goodies and another one not so great,” said Cade. “So, we add stuff to those that need it or remove unsafe items.”

Cade and his father, Aaron, take around 200 backpacks per trip along with food and water. Their last load included 25 cases of water, 500 pounds of food and 1,000 diapers for children.

“The response we’ve had has been unbelievable. We now have hundreds of backpacks reaching all the devastated islands of the Abacos and even to the shelters in Nassau,” Aaron noted.

For more information and to check current status on backpack donations, visit the Facebook page, “Backpacks for the Bahamas.”

A child is seen dropping off more backpacks for the hurricane relief project.

The entire Frye family: Aaron, Amanda (wife), Tinsley (8), Blake (5) and Cade (11). Also pictured is Reverend Kenneth Lewis from the St. Paul Methodist Church in Freeport, Grand Bahama and Vida Hepburn, owner of the Bootle Bay fishing lodge, where the Fryes dock to bring supplies, and access Freeport and West End, Grand Bahama. Both Vida and Rev. Lewis have been instrumental in making sure the backpacks and supplies reach the people in need.

DECEMBER 2019 | OR TODAY |

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INDUSTRY INSIGHTS

Johnson & Johnson

Moving Beyond Wellness Programs: Three Steps to Addressing Employee Burnout at Health Systems

By Melinda Thiel and Raphaela F. O’Day urnout and disengagement are deeply impacting clinicians and health system employees across the country.

Some reports suggest that over 50 percent of health care professionals1 – particularly those in front-line surgical specialties, such as trauma and general surgery2 – are experiencing symptoms of burnout. In fact, the World Health Organization has recently determined that burnout is an “occupational phenomenon.”3

B

Recognizing this still-growing challenge, health systems are starting to act. Eightynine percent of health system leaders report their health system is driving efforts to address burnout and workforce needs, according to the Johnson & Johnson Medical Devices Companies’ second annual survey conducted among OR clinicians and health system executives.4 However, implementing a successful program to address workforce wellness and health requires a thoughtful, tailored solution – particularly at health systems.

To deliver success, it is critically important that solutions go beyond employee wellness and address the root causes of burnout and disengagement that are particularly relevant to clinicians working at the frontline of patient care, including compassion fatigue, emotional stress, cumbersome organizational processes and the burden of administrative tasks.

Here are three steps to tailor employee engagement programs effectively for health systems:

26 | OR TODAY | DECEMBER 2019

Step 1. Recognize the unique challenges front-line care providers face As head surgical nurse and perioperative administrator for more than two decades, Barbara Trattler says she, “loved every minute of the job,” but it took a toll – she saw her family too little, rarely exercised, slept poorly and suffered from stress-induced migraines.5 Nurses, like Trattler, are found to be experiencing compassion fatigue, a manifestation of the challenges of working in the health profession. These include physical (“just plain worn out”) and emotional (“walking on a tightrope”) symptoms as well as various triggering factors (“an unbearable weight on shoulder”).6 The result can be the inability to care well for others, leading to disengagement, burnout and increased numbers leaving the profession.7 And it’s not just nurses. “As physicians, we’re taught that work is a marathon and we must pace ourselves,” explains Eric F. Stamler, MD FACOG, a practicing OBGYN in Cincinnati, Ohio.8 “But extended periods of high workloads or stress is not sustainable and can lead to burnout and energy loss that profoundly affects our personal and professional lives.” Apart from physical and emotional factors, “too much time spent on bureaucratic tasks” and “EHR or other IT tools hurt my efficiency” were also found to be top contributors to burnout.9

Step 2. Consider that burnout has physical, intellectual and emotional aspects Employee engagement programs that address the variety of drivers and consequences of burnout – physical, mental, organizational – are more likely to be

successful. A recent study published in the American Journal of Health Promotion is the first to demonstrate that a short, intensive workplace wellness intervention can produce sustained improvements in quality of life and wellbeing.10 In addition to addressing physical well-being (i.e., nutrition, exercise, sleep and movement), the 2.5 day intervention focuses on behavioral changes to holistically manage energy and maximize purpose, including training on defining purpose, facing the truth and tactics to handle setbacks.

Step 3. Adapt your employee engagement program to address all dimensions of your workforce’s health and wellbeing needs Organizations hoping to address burnout should recognize the many factors associated with the problem. Our research suggests that these should include four categories: the health and wellbeing of individual employees, the organizational environment, the interpersonal interactions and relationships of employees within the workplace as well as employee professional fulfillment.11 Employee engagement programs must acknowledge that employee health and wellness is not one-dimensional. Even though many health care organizations have made personalized solutions like mindfulness training, massage, yoga, or one-on-one coaching available, clinicians don’t make use of these because they feel pressed for time or that their daily work frustrations are being overlooked.12 There are multiple drivers of burnout, and addressing just one of them – for example, just the physical – will only have limited impact.

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INDUSTRY INSIGHTS

Johnson & Johnson This approach holds the promise to achieve healthier outcomes for health system employees, as well as patients, who will benefit from clinicians working to their fullest ability. At the Johnson & Johnson Medical Devices Companies, we’ve developed our Healthy Workforce offerings specifically for health care with the multifaceted nature of burnout in mind. It is designed to reduce clinician burnout through comprehensive employee engagement strategies that can lead to increased vitality, improved purpose and greater health and wellbeing for employees. Employee engagement programs have great potential to address clinician burnout – however, to be successful, health system leaders should take these three steps into account to develop the best program for their workforce and organization.

Melinda Thiel is the vice president, health system value transformation, Johnson & Johnson Medical Devices Companies.

Raphaela F. O’Day, Ph.D., is the senior performance coach and innovation catalyst, Johnson & Johnson Health and Wellness Solutions.

References 1 https://newsnetwork.mayoclinic.org/discussion/physicians-and-burnout-its-getting-worse/ 2 https://www.facs.org/education/division-ofeducation/publications/rise/articles/burnout/ 3 https://www.who.int/mental_health/evidence/burn-out/en/ 4 https://www.jnjmedicaldevices.com/sites/ default/files/user_uploaded_assets/pdf_assets/2019-09/JJMDC%20Health%20System%20 Exec%20and%20Clinician%20Survey%20 White%20Paper%20FINAL%208.26.19.pdf 5 https://www.jnj.com/innovation/caringfor-care-providers-a-new-way-to-help-address-

doctor-and-nurse-burnout 6 https://www.ncbi.nlm.nih.gov/ pubmed/28231623 7 https://www.beckershospitalreview.com/ workforce/49-of-nurses-have-considered-leavingthe-profession-in-the-last-2-years-study-finds.html 8 https://www.jnj.com/health-systems-canaddress-clinician-burnout-and-increase-employeeengagement-with-the-help-of-healthy-workforceofferings-from-the-johnson-johnson-medicaldevices-companies 9 https://medcitynews.com/2019/03/physician-burnout-ehr-satisfaction/ 10 https://journals.sagepub.com/doi/ full/10.1177/0890117118776875 11 https://www.jnj.com/health-systems-canaddress-clinician-burnout-and-increase-employeeengagement-with-the-help-of-healthy-workforceofferings-from-the-johnson-johnson-medicaldevices-companies 12 https://www.kevinmd.com/blog/2019/04/ innovative-approaches-to-solve-physicianburnout.html

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IN THE OR

market analysis

Headline Headline Deck Reports Forecast Medical Waste Market Growth Staff report he medical waste management market is expected to continue to grow in the coming years. This includes the growth of the operating room and surgery center segments of the overall market.

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The global medical waste management market is projected to grow at a compound annual growth rate (CAGR) of 4.09% to reach $18 billion by 2024, up from $14 billion in 2018, according to ResearchAndMarkets. com.

Waste that is generated during surgical processes is known as surgical waste. Surgical waste is both hazardous and non-hazardous. Out of the waste generated from surgeries, 85% is non-hazardous and 15% is hazardous.

Surgical waste is a huge threat to the environment. Hence, it necessitates proper disposal. Annually, around 250 million surgeries are carried out across the globe, which results in the bulk generation of surgical waste. On average, annually, more than two million tons of surgical waste is being generated. Each day, 5,500 tons of surgical waste is being generated, out of which, approximately 825 tons is hazardous surgical waste. Injections and syringes constitute the bulk of medical waste.

Globally, each year, more than 12 billion injections are used, out of which, 30% are for surgical procedures. The mishandling of these injections will

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lead to the spreading of infectious diseases like human immunodeficiency virus (HIV), Ebola virus disease (EVD) and other pathogenic problems.

Analysts forecast that the global surgical waste management market will grow at a CAGR of 5.83% during the period 2017-2021, according to ResearchAndMarkets.com One trend in the market is a growing demand for automation in surgical waste management.

“The growing focus of vendors on technological advancements has led to the development of automated equipment to dispose surgical waste. The adoption of advanced products helps with the proper and quick disposal of surgical waste. Technological advancements and automation have minimized the manual work associated with the disposal of surgical waste.

Technology has enabled the remote collection, separation and disposal of surgical waste,” according to ResearchAndMarkets.com.

“Also, advancements in incineration have resulted in the use of sensors, which help with the segregation of different types of waste. Robotic technology is also being used in the separation of huge volumes of surgical waste in a short period of time. For instance, ZenRobotics has created a robotic-assisted sorting system that is equipped with multiple sensors, 3D laser scanners and visible spectrum

cameras,” according to ResearchAndMarkets.

The rising global population is giving rise to a greater number of patients increasing the growth of the medical waste market. Furthermore, government initiatives regarding the safe disposal and management of medical waste will continue to drive the market growth in the coming years, according to ResearchAndMarkets.com.

“The growing population across the globe is increasing the number of patients, resulting in the rising volume of medical waste,” according to Mordor Intelligence. “Thus, with the rising volume of medical waste, the governments, worldwide, are taking several initiatives for the management of medical waste.”

The increasing number of initiatives by government authorities is driving the medical waste management market. Several federal bodies maintain laws concerning medical waste. These include the Occupational Safety and Health Administration (OSHA), the Centers for Disease Control (CDC), the U.S. Food and Drug Administration (FDA), the Department of Transportation (DOT) and the Drug Enforcement Administration (DEA).

Some other factors, like rising awareness regarding medical waste and eco-friendly options, are also impacting market growth.

DECEMBER 2019 | OR TODAY |

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IN THE OR

product focus

Skyline Medical STREAMWAY System

The FDA-approved STREAMWAY System, from Skyline Medical, is a true direct-to-drain option for surgical suites. It provides automated collection, measurement and disposal for an unlimited amount of medical waste fluid. The system’s compact and unique design virtually eliminates health care workers’ exposure to irrigation and patient fluids. From nurses to turnover staff, the antiquated and expensive approach of physically handling waste fluid is an unnecessary exposure risk for all health care workers involved. In addition, the STREAMWAY System is eco-friendly as it addresses the millions of bloody, potentially disease infected canisters that would otherwise go to the landfill. • For more information, visit skylinemedical.com.

Daniels

Surgismart Container The Daniels Surgismart container provides hands-free disposal of sharps and surgical devices in a fast-paced OR environment; this solution was designed with a large opening for easy collection of large or bulky items, and is supported by a foot-pedal operated Accessmart trolley for handsfree disposal and infection risk reduction.

The Accessmart is designed to facilitate co-mounting of additional sharps or pharmaceutical containers for dual-segregation.

Daniels’ clinically designed sharps containers are proven to reduce needlestick injury rates by up to 87%, and are supported by a robotic washing process that delivers the highest rates of decontamination. •

30 | OR TODAY | DECEMBER 2019

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IN THE OR

product focus

Ecolab

ISOLYSER Fluid Solidification Bio-hazardous liquids in the clinical environment represent one of the most difficult to contain sources of potential contamination for health care workers and patients. That’s why Ecolab offers multiple ISOLYSER fluid solidification products for everything from point of generation encapsulation and treatment of medical waste to solidification and safe disposal. Essential in practically every hospital or health care facility, Ecolab fluid control products help assure increased safety in handling infectious liquids. Equally significant, each product is easy to use and cost efficient. • For more information, visit ecolab.com/ fluidsolidification.

MD Technologies Inc. Environ-mate DM6000

MD Technologies Inc. Environ-mate DM6000 units reduce plastic (e.g. fewer canisters) meaning lower incineration or landfill demands, and lower costs. About 80% of fluid management cost is for canisters, and about 20% for waste disposal. Environ-mate units eliminate both costs for tremendous savings. Other systems require transporting suctioned fluid to disposal sites. These wallmounted units silently dispose fluid from the suction field directly to drain/sewer, protecting staff in Sterile Processing (DM6000), Endoscopy (DM6000-2-shown) and Surgery/ OR (DM6000-2A). Environ-mate requires drains, best installed during construction or remodeling. • For more information, contact us at 800-201-3060.

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DECEMBER 2019 | OR TODAY |

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CE210-60

IN THE OR

continuing education

Recognizing DrugSeeking Behavior

BY SUSANNE J. PAVLOVICH-DANIS, MSN, RN, ARNP-C, CDE, CRRN

t’s 3 a.m. Sunday when the triage bell sounds. It’s Linda, a 37-year-old patient who is well known to ED staff, complaining about her “usual” migraine. Of course, she has a “bad one that Imitrex won’t touch.” And the latest neurologist she saw “just doesn’t understand my condition and won’t give me medication that works.” All he suggested were nonsteroidal anti-inflammatory drugs, to which she insists she’s allergic, despite no documentation of any reaction in her extensive charts. Grimacing and photophobic, Linda appears upset and nervous in triage.

Oddly though, minutes later, when you call her back into the treatment area, she’s watching TV, smoking, and laughing. But as soon as you call her name, she displays an expression of sheer agony, shielding her eyes from the light.

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James calls the office at 4:30 Friday afternoon. He has had back pain all week and wants his wife to pick up prescriptions for Vicodin and Soma on her way home from work. He understands the office is busy; an appointment now would be impossible. James says he doesn’t need to be seen because it’s his “usual” pain, and he’s had his wife pick up his medications for him previously.

Timothy is at his primary care clinic two times a month with painful herpetic lesions around his urinary meatus.

Each time he receives a prescription for 30 Percocet tablets he requests to “get me through.” You’re moonlighting in an ED one weekend when Timothy arrives.

Staff nurses tell you he’s a regular and that “the physicians usually give him what he wants to get rid of him.”

What could these three patients have in common? They may be drug seekers: patients whose behaviors, requests, or mannerisms are aimed at obtaining addictive substances for nontherapeutic individual use or resale. For example, Linda and James may need to obtain medications to

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

Goal and objectives The goal of this continuing education program is to enhance the ability of nurses to identify and respond professionally to drugseeking patients. After studying the information presented here, you will be able to: •

Describe three types of drug-seeking patients

•

Differentiate among addiction, pseudoaddiction, and drug dependence behaviors

•

Identify four cues exhibited by drug-seeking patients

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continuing education satisfy an addiction or pseudoaddiction while Timothy may want to stock up on prescription drugs so he can sell them illegally on the street.

Drug seekers vary in age, gender, and socioeconomic status and may be hard to recognize. They may be unaware of their behavior or, conversely, deliberately deceive healthcare workers. Their behavior may frustrate nurses, evoking ineffective interventions or provoking outright hostility. Drug seekers may be difficult patients; they require careful observation, intervention, and documentation if their true problems are to be remedied. Would you be able to recognize and differentiate them from other patients?

Is Drug Seeking a Problem?

Modern U.S. drug laws evolved from the Harrison Narcotics Tax Act of 1914, although the significance of narcotic abuse as a medical concern was documented much earlier in the 1878 writings of Edward Levinstein, a German physician.1 Currently, the Controlled Substances Act of 1970, which went into effect in 1971, mandates the strict regulation of controlled substances. The act delineates five specific categories or schedules of drugs based on their actual or relative abuse potential, related potential for individual or public harm, current knowledge of pharmacological properties, and the scope and pattern of abuse of the substance or similar substances.2 As new drugs are approved and new nonprescription substances are identified, the list is revised.

In a multiyear analysis of the 2012-2014 National Survey on Drug Use and Health, the Center for Behavioral Health Statistics and Quality found that prescription psychotherapeutics, including pain relievers, were the second most popular category of illicit drug use after marijuana.3 Every day, a prescription opioid is abused

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for the first time by 1,200 people ages 12 to 17.3 Data from the 2016 National Survey on Drug Use and Health show that 2.1 million people ages 12 and older were new users of nonmedical prescription opioids in 2016.3 Data from the 2016 survey reveal that in the previous month:4 • An estimated 6.2 million Americans ages 12 and older had misused psychotherapeutic drugs at least once, representing 2.3% of their age group.

• An estimated 3.3 million Americans ages 12 and older had misused pain relievers, representing 1.2% of their age group.

• An estimated 2 million Americans ages 12 and older had misused tranquilizers, representing 0.7% of their age group.

• An estimated 1.7 million Americans ages 12 and older had misused stimulants, representing 0.6% of their age group.

• An estimated 497,000 Americans ages 12 and older had misused sedatives, representing about 0.2% of their age group.

Because we are in the midst of an opioid abuse epidemic, drug seeking is especially problematic. In 2016, more than 63,000 people died from drug overdoses. More than 42,000 of those deaths involved opioids, both prescribed and illicit.5 Diversion of drugs from legal and medically necessary purposes to illegal and medically unnecessary purposes is a significant concern.6 The increase in diversion, misuse, and abuse of prescription opioids has led to an increase in deaths attributed to overdose, with more than 46 people in the U.S. dying every day from prescription opioid overdoses.7 Numerous studies correlate substance abuse, which often includes legal prescriptions, with an increased incidence of major social problems,

including AIDS/HIV, homelessness, and crime.8,9 Healthcare professionals themselves contribute to the problem. For example, the abuse of prescriptive authority has drawn widespread attention from a U.S. House of Representatives subcommittee investigating Medicaid fraud. An alarming 21% of every Medicaid dollar is spent for substance abuse-related care.10 There have been historical concerns that some physicians weren’t performing adequate patient evaluations or prescribing responsibly, leading to accusations that they are “drug dealers armed with prescription pads.”10 Physicians often report difficulty discussing substance abuse and confronting patients about misused or diverted prescription drugs.9,11 Although many drug seekers acquire prescriptions merely by manipulating healthcare professionals, the providers themselves, whose activities are sometimes financed by fraudulent healthcare claims, fuel the problem.

For example, providers might order controlled substances, sometimes in conjunction with various types of therapies (often provided in-house) to justify the prescriptions, then bill insurance companies for frequent visits without actual illnesses or injuries to support these interventions.10 These activities are especially common with benzodiazepines (prescribed for anxiety) and pain relief medications. An apathetic “why bother?” attitude interferes with the need to confront drug seeking and abuse.

Who are the Real Victims?

Drug seeking victimizes the seekers, other patients, and healthcare professionals. Drug seekers become victims of their own diseases, poor pain management, addiction, and criminal behavior. At the same time, they exploit the healthcare system,

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continuing education divert resources and time from other patients, erode public confidence in the professionals they scam, contribute to family discord, and become potential safety threats to themselves and society.12 Healthcare professionals who appear to abet illegal drugseeking behavior risk loss of their medical licenses and/or revocation of their controlled-substance dispensing numbers issued by the Drug Enforcement Administration.9,2 Drug seekers have good reasons to bypass traditional street drugs and seek out healthcare professionals for prescription medications. These drugs have better potency, consistency, purity, availability, and resale value; also, with professionally delivered injections, there is less risk of HIV transmission. Contributing to the appeal of prescription medicines is enhanced access to emergency services, thanks to laws that mandate care regardless of ability to pay (such as the Emergency Medical Treatment and Active Labor Act), as well as social and assistance programs that provide prescription drugs at little or no cost.10 Even the emphasis by managed care on efficient healthcare delivery systems has the potential to boost the availability of prescription drugs.

For example, while physicians say access to prescription history would change their prescribing methods, the reality of a busy practice can mean that shorter visits are the goal, leading physicians to write prescriptions without taking time to check prescription drug monitoring programs (PDMPs).11 It is difficult to gain a full understanding of drug seeking because it is difficult to study what is unlawful.12 Legally obtained prescription medications may be sold to purchase illegal drugs or finance prostitution.13 Street markup for psychoactive prescription drugs is considerable – up to 40

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times their value – and the use of these drugs is diverse. Some potent sedatives, hypnotics, and opioids are crushed, diluted, and injected, while antihypertensive medications such as clonidine (Catapres) are taken by mouth to manage withdrawal symptoms of cocaine or heroin. Research indicates that clonidine (prescribed off-label) not only helps manage withdrawal symptoms, but also is effective in reducing drug craving and delaying relapses.14

Understanding Drug Seeking One force that drives patients to seek out prescription medications is the complex, subjective phenomenon of pain. Many healthcare professionals have difficulty evaluating it. The extent of pain can be masked by stoic behavior, exaggerated by hysterics, or disguised by coexistent psychological problems. It is also hard to differentiate the behavior of patients driven by pain from the behavior of those with other motives. With increased access to technology and the widened availability of electronic medical records, the possibility of gaining access to patients’ histories of drug use represents one tool ED professionals could use before prescribing additional medications.11 Many states now have PDMPs to collect information about controlled substances that have been prescribed and dispensed. PDMPs may be accessed only through state authorization.

Most patients who complain of pain don’t seek a euphoric state but relief from disabling or unbearable discomfort. Among them, however, are patients who seek drugs to cope with addictions or provide them with illicit incomes. It takes experience gained through exposure and a keen eye to differentiate among them.

Other forces behind drug seeking and abuse – addiction, pseudoaddiction, tolerance, and physical depen-

dence – are often misunderstood. For example, addiction has been wrongly equated with physical dependence and tolerance. Pseudoaddiction is a complicated phenomenon that often goes unnoticed.

Addiction is a psychological dependence on or craving for drugs.

It is a chronic, relapsing, yet treatable disease that is characterized by both denial and compulsivity in the addict, who is constantly searching for the psychological effects of mood-altering substances, often using them in combination.15 Addicts who are not in treatment or recovery no longer have control over their drug use despite its harmful, negative effects, including even criminal prosecution.12,15 One of the surest signs of addiction is lack of improvement or worsening of psychological well-being and social or vocational function despite the best possible efforts to control pain. Depending on the drug(s) abused, the person may also exhibit impulsive behavior, anxiety, mood disturbance, and cognitive dysfunction.12,15 Addicts sometimes use medications prescribed to them in ways that intensify their effects, such as taking them on an empty stomach, with alcohol or other drugs, or at dosages or frequencies exceeding what was prescribed. Consequently, addicts often run out of medication earlier than expected.12 Pseudoaddiction is a behavioral manifestation of inadequate pain control. Unrelieved pain can cause so much anxiety and distress that some patients develop the mindset of an addict. They try to procure more medication because their pain is unrelieved, or they are in anticipation or fear of running out. The resulting drug-seeking behavior may lead healthcare professionals to inappropriately identify these patients as addicts.16 It is important to remember that pain management is the most

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continuing education common force driving patients to seek prescription medications, and research indicates that inadequate management of acute pain may potentiate a chronic pain syndrome.17 Tolerance is the need for an increased dosage to produce the same effect or level of analgesia previously experienced.16 This physiologically learned cellular response involving multiple brain regions may be acute or chronic, depending on pharmacokinetic properties and individual metabolic factors such as the ability of the liver or kidneys to excrete the drug. Research indicates that opioid tolerance may induce abnormal pain sensitivity, or actually render medication less effective or even enhance the sensation of pain.16 Tolerance, a neurobiological response common in pain management, isn’t always obvious and doesn’t necessarily signal addiction.16 Physical drug dependence is the neurobiological basis for drug craving, when brain pathways related to brain glucose metabolism and mechanisms within the dopaminergic and limbic systems act to positively reinforce and reward drug use.16 Environmental cues such as increased social acceptance by peers also reinforce drugcraving and drug-seeking behaviors.

Physical drug dependence is manifested by withdrawal symptoms after abrupt discontinuation of the drug or if an antagonist is administered.16 Although this dependence isn’t the same as the psychological problem of addiction, it may occur together with either addiction or pseudoaddiction.16

A Taxonomy of Drug Seekers Drug seekers are informed people.

They know preferred medications by name, strength, color, price, and manufacturer – often better than prescribing practitioners. The most sought-after substances include opioid pain medications, benzodi-

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azepines, stimulants, hypnotics, and barbiturates.4,11 It’s nearly impossible to establish a single profile for drugseeking people, because their motivations are diverse. Some want drugs to use themselves for their own medical or psychological reasons; others want to sell drugs so they can support their criminal activity. However, for easier recognition, drug seekers can loosely be categorized as user-abusers (those who consume drugs themselves for varied reasons) and entrepreneurs (who obtain and sell drugs).

User-abusers seek drugs because of addiction, pseudoaddiction, or physical drug dependence.18 They may have initially used prescribed medications for valid medical conditions but now use them for other reasons, despite negative consequences.

Some are professional patients who exploit chronic medical conditions or feign illness to obtain drugs.

They know the medical aspects of their disease; they use resource materials such as the Physicians’ Desk Reference or textbooks not generally available to the public; or they use medical jargon or buzzwords that are familiar to clinicians. For example, the patient may complain of a migraine that is “intense, but has my usual pattern,” meaning that treatment requires only medication and not diagnostic tests.19 Professional patients may request parenteral medication or report pain levels “greater than 10 out of 10” – behavior identified as potentially predictive of drug seeking by doctors who have been scammed by patients.9 Professional patients try to persuade providers to diagnose by history; when tests are performed, they may try to make the results fit their alleged disease. For example, professional patients may taint urine specimens with blood to emulate renal pathology or arrive with their own diagnostic reports from prior

“workups.” Usual complaints include dental abscesses or toothaches, back pain, colitis, orthopedic problems, metastatic cancer, narcolepsy, headaches, tic douloureux, carpal tunnel syndrome, sciatica, diabetic neuropathies, painful herpes simplex lesions, shingles, depression or anxiety, insomnia, and sickle cell disease.18 Professional patients attempt to control the interview and apply psychological pressure on healthcare providers. They often refuse workups or, if they perceive that they will not receive their prescriptions of choice, leave before treatment is completed.

On the other hand, they may be overly talkative, polite, and friendly with staff members, trying to evoke sympathy and manipulate them to dispense the right drugs.

Pseudoaddicted patients are those who have been legitimately prescribed medication for pain management. As a result of inadequate pain control or fear of running out of medication, pseudoaddicted people engage in drug-seeking behavior to procure an adequate supply of pain medication. The cure for pseudoaddiction is comprehensive and frequent assessment of pain and adequate management.

Psychologically disturbed patients obtain prescriptions in association with mental illness. They may have schizophrenia, Munchausen syndrome, Munchausen syndrome by proxy, a tendency toward suicide or self-injury, or a dual diagnosis (mood disorder and substance abuse).

They may inflict external trauma on themselves or violate their own body cavities to create valid reasons for receiving medications. They may present with problems such as ruptured tympanic membranes, trauma to their mouths or nasal mucus membranes, corneal abrasions, soft tissue injuries, bruising, fractures, or vaginal bleeding inconsistent with menstrual flow.18

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continuing education Substance abuse – particularly with amphetamines, sedatives, and hallucinogenic drugs – is much more common among this group than among the general population.16 Entrepreneurs are “street pharmacists” who obtain prescriptions for medications that can be resold for profit.18 Their tactics include stealing prescription pads, forging prescriptions, and calling in prescriptions by phone while posing as physicians.18 They are engaged in a covert business activity that entails few risks and great rewards for minimal effort.

Entrepreneurs may also rummage through treatment areas in search of drug paraphernalia having potential street value, such as needles, empty syringes, or partially filled or prefilled syringes.

Entrepreneurs often refuse diagnostic testing, intramuscular injections, or medications for immediate consumption. They encourage providers to prescribe a maximum quantity of pills or ask for a number that is easily converted to a larger one (for example, 9 can become 40 or 100 with the stroke of a pen).18 They also may request that prescriptions be written separately so they can selectively fill the ones they want, then discard the ones for medications without street resale value. Extendedrelease preparations of medications such as oxycodone (OxyContin), which can be crushed and used for immediate effects, are especially sought after.

Often entrepreneurs express a preference for a brand name drug over a generic because of street recognition that it’s “the real thing.”

They may even express a preference among drugs in the same class based on resale value – for example, preferring a high-dose hydrocodone/acetaminophen combination (Vicodin) with a street value of $30 per pill to an oxycodone/acetaminophen com-

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bination (Percocet) with a $20 street value per pill.12 Modern technology now even assists entrepreneurs: Using crowdsourcing, the Web site StreetRx displays the latest street prices across the country for prescription and illicit drugs. Entrepreneurs are often in a hurry because they may intend to visit several facilities or offices.

They know exactly what they want, adamantly refusing alternatives.

All types of patients and entrepreneurs may visit multiple providers and use multiple pharmacies, practices known as doctor shopping and pharmacy shopping. One study found that those who sold their prescription drugs were more likely to succeed in their efforts to deceive prescribers and obtain prescriptions than were individuals who sought prescriptions for their own personal use.19

What to Do Confronting a drug seeker can be therapeutic at best, dangerous at worst, and almost always difficult.

Although only nurses with advanced practice status have the authority to prescribe, all nurses are involved in the assessment, medication, and direct care of drug seekers.

Problems are apt to arise when these patients realize their quest for drugs might be unsuccessful. Some may simply leave when they realize they won’t get what they came for. Others may become hostile or intimidating, threatening suicide or litigation. Nurses should avoid confronting drug seekers by themselves and maintain professional boundaries, carefully assessing and intervening appropriately for the safety of the patient, themselves, and other staff.

They should not hesitate to involve social services, psychiatric support, security, or even police in extreme circumstances.18 Nurses should be cautious not to violate patients’ right to privacy.

Unless patients have consented to share information with other local EDs, that late-night call to warn other nurses of a potential drug seeker “on the hunt” may get you in trouble.

However, it’s considered within the norms of providing adequate and consistent healthcare to speak with a pharmacist about a prescription you suspect may have been tampered with.

Electronic surveillance systems and PDMPs have helped to uncover and document many drug-seekers’ behavior. PDMPs work by regulating both prescribing and dispensing behaviors. Some PDMPs monitor only Schedule 2 drugs, while others monitor drugs on Schedule 2 to 5.20 PDMPs locate sources of drug diversion by identifying fraud, forgeries, physician shopping, and improper prescribing. They also help inform public health initiatives through outlining use and abuse trends. One study found that a state PDMP reduces the per capita supply of prescription pain relievers and stimulants, which, in turn, reduces the abuse potential of these drugs.20 Nurses have an obligation to do no harm, and to knowingly support addictive or illegal behavior is unethical and may even be illegal. Nurses should not remain silent objectors when called on to medicate patients they believe are drug seekers. They need to appropriately voice their suspicions to prescribers, especially when this information may help to identify, diagnose, and treat abuse or criminal behavior. Nurses need to clearly and objectively document their concerns and observations (such as inconsistencies in behavior from the waiting room to the treatment area) in the medical record, using direct patient quotes whenever possible. Providers should be encouraged to review the entire medical record, not just the complaint data for that

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continuing education specific visit, before prescribing controlled substances.

Nurses need to move beyond the narrow role of controlling disease and injury and examine the psychodynamics behind their patients’ problems. Assessing and identifying substance abuse isn’t the responsibility of only psychologists or therapists, but of every healthcare provider. Treatment, however, should be reserved for specialists. Nurses can focus on assessment and clear documentation to help future referral. Meanwhile, nurses should secure prescription pads, sharps containers, and drug paraphernalia from possible theft.

Veteran drug seekers are eventually found out. Some enter treatment programs; others go to jail. A few die as a result of addictive or criminal behaviors. Most simply wear out their welcome at a facility or office and move on.

When dealing with suspected drug seekers, nurses need to strive for cautious balance. The desire to reduce drug diversion or abuse should not come at the expense of patients who need treatment for addiction or adjustments to their pain management programs.17 Nurses should be mindful not to label patients too quickly, but to identify and document behaviors that support their suspicion of drug seeking. Tips and cues presented in this module can sharpen the skills of nurses when they are evaluating suspected drug seekers.

References

7. Prescription opioid overdose data. CDC

1. Parssinen TM, Kerner K. Development of

Web site. https://www.cdc.gov/drugover-

the disease model of drug addiction in Brit-

dose/data/overdose.html. Updated August 1,

ain, 1870-1926. Med Hist. 1980;24(3):275-296.

2017. Accessed June 12, 2018.

2. Comprehensive Drug Abuse Prevention

8. Lipari RN, Van Horn SL, Hughes A, Wil-

and Control Act (Controlled Substances

liams M. The CBHSQ report: state and

Act), 21 USC §811, §812 (1970). Also avail-

substate estimates of nonmedical use of

able at https://www.deadiversion.usdoj.

prescription pain relievers. https://www.ncbi.

gov/21cfr/21usc/811.htm and https://www.

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deadiversion.usdoj.gov/21cfr/21usc/812.htm.

RB-3187.s1. Published July 13, 2017. Accessed

Accessed June 12, 2018.

June 12, 2018.

3. Lipari RN, Ahrnsbrak RD, Pemberton MR,

9. Lembke A. Drug Dealer, MD: How Doctors

Porter JD. Risk and protective factors and

Were Duped, Patients Got Hooked, and Why

estimates of substance use initiation: results

It’s So Hard to Stop. Baltimore, MD: Johns

from the 2016 National Survey on Drug Use

Hopkins University Press; 2016.

and Health. Substance Abuse and Mental Health Services Administration Web site.

10. Manchikanti L. Prescription drug abuse:

https://www.samhsa.gov/data/report/risk-

what is being done to address this new drug

and-protective-factors-and-estimates-sub-

epidemic? Testimony before the Subcom-

stance-use-initiation-results-2016-national.

mittee on Criminal Justice, Drug Policy,

Published September 2017. Accessed June

and Human Resources. Pain Physician.

12, 2018.

2006;9(4):287-321.

4. Ahrnsbrak R, Bose J, Hedden SL, Lipari

11. Greenwood-Ericksen MB, Poon SJ, Nelson

RN, Park-Lee E. Key substance use and

LS, Weiner SG, Schuur JD. Best practices

mental health indicators in the United States:

for prescription drug monitoring programs

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Drug Use and Health. SAMHSA Web site.

results of an expert panel. Ann Emerg Med.

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2016;67(6):755-764. doi: 10.1016/j.annemerg-

files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.

med.2015.10.019.

htm/. Published September 2017. Accessed June 12, 2018.

et al. Dynamic risk factors in the misuse 5. Confronting opioids. Centers for Disease

of opioid analgesics. J Psychosom Res.

Control and Prevention Web site. https://

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www.cdc.gov/features/confronting-opioids/

chores.2012.02.009.

index.html. Updated April 16, 2018. Accessed June 12, 2018.

EDITOR’S NOTE: Donna Rush, EdD, ARNP, CS, past author of this educational activity, has not had the opportunity to influence this version.

Susanne J. Pavlovich-Danis, MSN, RN, ARNP-C, CDE, CRRN, is an advanced practice nurse, certified diabetes educator, and certified rehabilitation nurse in private practice in Plantation, Fla.

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12. Pergolizzi JV Jr, Gharibo C, Passik S,

13. Ferguson KM, Bender K, Thompson SJ. Gender, coping strategies, homelessness

6. Drug diversion in the Medicaid program:

stressors, and income generation among

state strategies for reducing prescription

homeless young adults in three cities. Soc

drug diversion in Medicaid. Centers for

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Medicare & Medicaid Services Web site.

socscimed.2015.04.028.

https://www.cms.gov/Medicare-MedicaidCoordination/Fraud-Prevention/MedicaidIn-

14. Kowalczyk WJ, Phillips KA, Jobes ML, et

tegrityProgram/downloads/drugdiversion.

al. Clonidine maintenance prolongs opioid

pdf. Published January 2012. Accessed June

abstinence and decouples stress from crav-

12, 2018.

ing in daily life: a randomized controlled trial with ecological momentary assessment.

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continuing education Am J Psychiatry. 2015;172(8):760-767. doi:

the good, the bad, and the ugly of opioid

Miller BL. Deception and drug acquisi-

10.1176/appi.ajp.2014.14081014.

analgesics. J Neurosci. 2015;35(41):13879-

tion: correlates of “success” among

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drug-seeking patients. J Prim Care Com-

15. Fernández-Calderón D, Fernández F,

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Ruiz-Curado S, Verdejo-Garcia A, Lozano

17. Tighe P, Buckenmaier CC 3rd, Boezaart

OM. Profiles of substance use disorders in

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19. Sanders AN, Eassey JM, Stogner JM,

Clinical Vignette It’s 11 p.m. on a busy Saturday in your county’s busiest ED. The triage nurse comes back to the desk and quietly announces, “We’ve got a seeker out front.” Carol, 38, has been labeled a “frequent flyer” – a patient with genuine medical problems after a horrific automobile accident – who seems to visit the ED for pain medication way too often. She is employed full time as a cashier and has a primary care provider who “just doesn’t give me enough medication.” Her usual ED routine involves a pain injection and a short supply of pills to “tide me over.”

1. Based on Carol’s history, she is most likely seeking drugs because of:

a. An illicit scheme to sell drugs for profit b. An addiction to controlled substances c. Inadequate pain management d. Decreased drug tolerance

3. The cure for pseudoaddiction is:

a. Involuntary admission to a substance abuse program b. Law enforcement involvement c. Comprehensive pain assessment and management d. A trial of placebos 4. Most patients who complain of pain:

2. Carol demonstrates a physical need for an increased drug dosage to produce the same effect or level of previously experienced analgesia. This is known as:

a. Seek a euphoric state b. Seek drugs to cope with addiction c. Seek drugs to provide an illicit income d. Seek relief from unbearable discomfort

a. Addiction b. Pseudoaddiction c. Tolerance d. Dependence

Clinical VignettE ANSWERS 1. Answer C., Carol has a documented need for pain medication yet still seeks additional medication – a sign of inadequate pain management. Individuals who seek drugs for resale typically don’t accept injectable drugs in the ED. Carol is able to maintain a job, which is uncommon with addiction.

People who seek drugs typically have increased drug tolerance. 2. Answer C, Carol manifests drug tolerance – a physical need for an increasing dose to produce the same effect. While she may indeed have pseudoaddiction, it is unrelated to a physical need. Addiction is a psychological dependence or craving; dependence is related to a physical need that, if the drug supply is interrupted, will lead to withdrawal symptoms. 3. Answer C, Inadequate pain management causes pseudoaddiction, so the source of the pain must be appropriately addressed. Law enforcement involvement, substance abuse therapy, and placebo use do not address the underlying cause of the problem. 4. Answer D, The majority of patients complaining of pain seek relief.

A smaller percentage of patients seek drugs for addiction, illicit purposes, or euphoria, thus complicating the assessment and management of people who present in pain.

38 | OR TODAY | DECEMBER 2019

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CORPORATE PROFILE MD Technologies

COST SAV I N G S MADE IN T H E USA MD Technologies Inc. President William “Bill” Merkle shares about his company and the cost-saving products it supplies to health care facilities.

MD Technologies Inc. started in Arizona in 1989 when Merkle, an engineer, met Endoscopy Technician Kevin Druding. Druding had made a few suction-drain devices (Kevin’s Drain-O-Matic) to clean endoscopes using suction rather than manually irrigating with a syringe.

The two collaborated on product design, then patented and produced the first DM6000 Suction Drain System units, which are still in use today. Merkle moved to Illinois in 1991 but continued work with MD Technologies outside of his “day job,” incorporating in 1993. Druding elected to separate from MD Technologies Inc. in about 2005.

The DM6000 was initially created to make endoscope cleaning easier and more reliable, but units quickly began to be sold as replacements for disposable suction canisters because of staff protection and cost savings provided to health care facilities. The system name was changed to Environ-mate®. Two logical derivatives of the DM6000 are the DM6000-2 (endoscopy) and DM6000-2A (surgery/OR) units, developed later on.

Merkle shared more about the benefit of the DM6000.

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“There are actually two benefits,” Merkle explains. “The benefit to the staff is isolation from suction fluids that might be potentially infectious and the benefit to the facility is tremendous cost savings because there is no requirement for them to be

“ It provides employment for a couple dozen individuals at the workshop and as such it has been a tremendous success for the workshop as well as a great success for our company – providing jobs to individuals right here in the United States and right here in Galena.” purchasing the disposable supplies that they use with conventional fluid management.”

In 2002, MD Technologies introduced its PT20® Polyp Trap. The PT20® Polyp Trap is a single-chamber collector designed as an im-

provement over Lukens tubes used for urine, blood and stool samples which did not have screens.

Merkle explains that the PT20® Trap from MD Technologies is made in America and provides benefits to health care providers as well as to some important members of the Galena community.

“Our polyp trap, the PT20® trap, has a screw top and a very fine screen. The screw top helps minimize the risk of Clostridium difficile and the screen is wide open making it very easy to remove a specimen,” he says. “It is hand assembled in the United States and is actually very much favored among facilities. It is a little more expensive than what you might find with traps that are made offshore, for example in China.”

“The PT20® was specifically designed so that it could be assembled by developmentally challenged individuals at a local workshop right here in Galena,” he adds. “It provides employment for a couple dozen individuals at the workshop and as such it has been a tremendous success for the workshop as well as a great success for our company – providing jobs to individuals WWW.ORTODAY.COM

CORPORATE PROFILE

MD Technologies

The made in America PT20® is designed so that it can be assembled by developmentally challenged individuals at a local workshop in Galena, Illinois.

right here in the United States and right here in Galena.”

The company purchased Promethean Medical Technologies LLC in 2010 and now offers the Promethean Island suction floor mat to provide a comfortable walking surface while keeping the OR floor dry. Most recently, MD Technologies introduced the FM99, a filter/ manifold that provides four connections for arthroscopy (scope, shaver and two auxiliary, low flow connections).

OR Today found out more about the company with a question-andanswer session with Merkle.

Q: What are some advantages that MD Technologies has over the competition?

A: Our company is small and nimble. When a customer calls, they reach live individuals. We offer support on the spot without a customer having to wait for a response. We offer personal recognition of customers without relating to accounts or numbers for various facilities and individuals. We address reported WWW.ORTODAY.COM

problems as soon as we are aware of them, typically within one business day.

Q: What are some challenges MD Technologies has faced recently?

A: Over the past few years, and particularly recently, we have been challenged by an increased demand for many of our products, while at the same time facing increased pressure to reduce prices on some of our other products.

Q: Can you share MD Technologies core competencies and unique selling points?

A: Our core competencies include the ability to listen to customer preferences and respond with products and services that address those demands. We are uniquely experienced since the late 1980s in fluid management matters, and we provide a comprehensive product offering to address fluid management issues.

Product Advantages/Selling Points • Environ-mate® DM6000 Series

Suction-Drain Systems: Advantages include a rugged design. Unit life exceeds 25 years with minimal requirements to replace the consumable components. Naturally, this requires that routine maintenance (cleaning) be respectfully conducted. Selling points include cost savings. The units pay for themselves within one year generally, while protecting staff from exposure to suctioned fluids. Wall-mounted units silently dispose of fluid without taking up valuable floor space, using excessive amounts of water or requiring secondary transport to a disposal site.

• PT20® Trap: Advantages include a screw top, removable finemesh white screen and clear container. Selling points include minimized risk of C. diff. when opening the container, easy retrieval of polyps from the white unobstructed fine mesh screen and, of course, reliable poly capture without damage.

• Promethean Island®: Advantages include a large area flexible floor mat, non-absorbent materials and a suction connection. Selling DECEMBER 2019 | OR TODAY |

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CORPORATE PROFILE MD Technologies

Above: The Environ-mate® DM6000 Series Suction-Drain Systems pay for themselves within one year generally, while protecting staff from exposure to suctioned fluids.

Left: The Promethean Island suction floor mat provides a comfortable walking surface while keeping the OR floor dry.

points are a comfortable anti-fatigue walking/standing surface, ability to measure deficit fluids (not collected by fluid collection system from procedure) and reduced slips/falls due to wet OR floors.

maintain our suction-drain systems will simplify maintenance for those customers and assure even longer system life than today.

Q. What product or service are you most excited about right now?

A: On several occasions, we have assisted physicians and nurses in retrieving tissue that had been inadvertently collected by one of our suction-drain systems because either a trap was not installed, or maybe the trap did not feature a reliable screen (they should have used a PT20® Trap!). In each case, we were able to assist the physician or nurse in retrieving the tissue.

A: At present, we are most excited about our FM99 Filter/Manifold, which permits four suction fields to be connected to one suction source.

Suction level of each field will obviously be reduced compared to source suction, but the device is designed to accommodate two higher flow and two lower flow fields, and tests have validated this design.

Q: What is on the horizon for MD Technologies?

A: We are constantly reviewing and revisiting the design of our products to reduce costs so that our products can be offered at the lowest prices to meet the aggressive pricing demanded by today’s market.

We expect to emerge with some very competitive pricing that will result in markedly increased sales.

Improvements in procedures to

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Q: Can you share a time that you “saved the day” for a customer?

Q: Can you highlight any recent changes to your company?

A: The company has remained largely unchanged over the past several years, except that we continue to increase the number of unit installations and customers using our products. The new Filter/Manifold is the latest addition.

Q: Can you tell me about your employees?

A: Two unsung heroes of our com-

pany include Melissa Merkle and Janice Watson. Melissa is my wife, handling all day-to-day operations, and Janice is the work floor supervisor at the workshop where the PT20 is assembled.

Q: What is your company’s mission?

A: Our most important goal is to satisfy our customers. We ignore profit when it comes to addressing a customer need. Our focus is on fluid management and handling fluid prior to disposal to assure collection of any fluid borne tissue as necessary.

We also strive to provide meaningful employment, in assembly of our traps and filters, for individuals with developmental challenges.

Q: Is there anything else you want readers to know about MD Technologies?

A: We are so grateful to have the opportunity to have served, and continue to serve, the health care industry, the endoscopy community and individuals with developmental challenges.

For more information, visit MDTechnologiesInc.com.

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LET IT

FLOW

By Don Sadler

EFFICIENT

TRANSITIONS

E L E VAT E

CARE

here are few things that can cause more problems in hospitals than poor patient flow in the perioperative setting. Perioperative services is one of the most interconnected units in a hospital, so inefficient flow of patients through the perioperative area can cause disruptions that ripple throughout the entire organization.

T

“Efficient patient flow means that each individual patient moves through the surgical experience as planned,” says Erin Kyle, DNP, RN, CNOR, NEA-BC, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN). “Each individual patient’s movement is in harmony with the movement of other patients.”

A Seamless Transition Kristin Ray MSN, RN, CPN, NE-BC, director of nursing for pre-admission testing at Children’s Mercy Kansas City, describes efficient patient flow as “a seamless transition between phases of care throughout the surgical journey.”

“With efficient patient flow, bottlenecks and unnecessary wait times for patients are minimized through thorough pre-operative coordiWWW.ORTODAY.COM

nation of care,” says Ray. “Streamlined communication between perioperative team members and appropriate and timely signaling to the next phase of care when the patient is ready to advance also help improve patient flow.”

When patient flow through the perioperative area is smooth, “patients with higher acuity who need more resource utilization don’t interfere or compete with other patients’ needs at the time of preoperative preparation, surgery and recovery,” says Kyle.

“Every patient receives the undivided attention of physicians, perioperative RNs and all members of the perioperative team,” Kyle adds.

Conversely, poor or inefficient patient flow can lead to a number of negative consequences, says Desiree Chappell, MSNA, CRNA, associate editor and U.S. lead, TopMedTalk. “This DECEMBER 2019 | OR TODAY |

45

includes confusion among patients and their families, which can impact HCAP and patient satisfaction for the hospital and providers.”

Other problems associated with poor patient flow include OR backlog, increases in call time and overtime pay, increasing PACU holds, and issues with discharge for outpatient and bed utilization throughout the rest of the hospital, says Chappell.

“Unforeseen and last-minute surgery cancellations are extremely costly because they create empty OR block time,” says Ray. “Staffing cannot be adjusted in advance to match the empty OR time and decreased case load.”

“During high hospital census, patients who have met the criteria to move on to the next phase of care can be held in the OR or PACU. Holding a patient in these high acuity areas for a long period of time comes at an increased cost to the patient,” Ray adds.

“UNFORESEEN AND LAST-MINUTE SURGERY CANCELLATIONS ARE EXTREMELY COSTLY BECAUSE THEY CREATE EMPTY OR BLOCK TIME.” Factors That Impact Patient Flow According to Kyle, patient flow can be impacted by a number of different things that are out of the hospital’s control. These range from manpower or personnel issues to scheduling and activity sequencing, equipment and supplies, and patient concerns.

“Also, health care workers are human and have human needs,” Kyle adds.

“Sometimes they’re ill and can’t come to work. Or maybe they come to work sick and are less productive, or they have to leave work early due to per-

46 | OR TODAY | DECEMBER 2019

sonal or family issues.”

Chappell believes that a lack of team communication and a lack of education are key contributors to inefficient patient flow. Kyle agrees.

“When any of these issues are coupled with poor communication, the loss of efficiency is magnified exponentially,” Kyle says.

Ray lists a number of other contributors to inefficient patient flow, including the following: • Space constraints • Budget restrictions for equipment needs • Inpatient post-op bed availability • Last minute schedule changes • The redesign of space to support LEAN methods and strategies • Block time rearrangements to accommodate emergent and urgent cases

What Smooth Patient Flow Looks Like So what does efficient patient flow look like? Kyle lists a number of characteristics of a perioperative services area with smooth patient flow: • Surgery scheduling allows for cooperative use of resources with effective planning. “For example, overlapping procedures needing the same equipment are not scheduled simultaneously,” she says.

• Patients arrive for surgery with adequate time to effectively prepare for surgery.

• Every member of the perioperative team has been given a clear assignment, which allows them to be prepared for all aspects of each assigned patient’s needs.

• The surgeon arrives in advance of the surgical procedure to perform preoperative duties and is not interrupted with competing demands on his or her time.

• Every member of the perioperative team has the supplies, equipment,

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time and support needed to move efficiently through the day. “In other words, they don’t have to waste time searching for missing items,” says Kyle.

• The post anesthesia care unit can admit and discharge patients when they’re ready for admission or discharge. “This unit shouldn’t be serving as a holding space due to a lack of resources or space in the receiving unit,” says Kyle.

• Disruptions that are common in the management of surgery schedules are anticipated and handled in such a way that the schedule is not disrupted. “There should be a plan for common add-on procedures and emergency procedures that doesn’t disrupt scheduled procedures or surgeons’ schedules,” says Kyle.

Steps to Improving Patient Flow According to Chappell, patient flow can be improved via enhanced education of health care providers at all levels. “They need to be educated not only about their specific jobs, but also about their role in the efficiency of patient flow,” she says.

Ray recommends using an electronic tracking board to communicate each patient’s current destination and readiness for each stage in the perioperative process. “You should also perform daily readiness and safety huddles at the start of each day and designate a surgical observation unit specifically for patients who require a short stay after surgery,” she adds.

Kyle says that improved patient flow starts with two main things: preparedness within all phases of perioperative care – including patient, supply and equipment, team availability and competency, and environmental – and correct scheduling.

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“These two concepts are closely related and interdependent,” Kyle says.

“However, improved patient flow is sustained when an organization uses data to inform decisions, fosters a culture of safety, maintains appropriate staffing levels, and provides the resources needed by staff to perform their jobs correctly,” Kyle adds.

How ERAS Can Improve Patient Flow Chappell believes that Enhanced Recovery After Surgery (ERAS) can play a significant role in improving patient flow through the perioperative continuum.

“A basic tenant of an ERAS program is standardization through protocols and pathways,” says Chappell. “The benefit of standardization is that everyone is on the same page and throughput improves.”

Chappell points out one caveat to using ERAS to improve patient flow: the steep learning curve during implementation, especially if implementation is unorganized and there’s a lack of education during the process.

“But it all circles back to managing expectations, education and communication,” she says.

According to Kyle, there are great resources for improving the efficiency of patient flow in the AORN Perioperative Efficiency Toolkit. “The toolkit includes practical strategies for optimizing perioperative patient flow,” she says.

KRISTIN RAY MSN, RN, CPN, NE-BC,

director of nursing for pre-admission testing at Children’s Mercy Kansas City

ERIN KYLE

DNP, RN, CNOR, NEA-BC,

perioperative practice specialist with the Association of periOperative Registered Nurses (AORN)

For more information, visit https:// shop.aorn.org/aorn-perioperative-efficiency-tool-kit/ to order a copy of the AORN Perioperative Efficiency Toolkit.

The resource is free to AORN members and costs $11 for non-members.

DESIREE CHAPPELL MSNA, CRNA,

associate editor and U.S. lead, TopMed

DECEMBER 2019 | OR TODAY |

47

B Y M AT T S KO U FA LO S

S P O T L I G H T

O N

PAMELA DAVIS

A SSISTANT HEAD NURSE, MOUNT SINAI HEALTH SYSTEM

amela Davis will be the first to tell you she’s not a typical 61-year-old. An assistant head nurse at Mount Sinai Health System in New York, she’s at the point in her career where she knows “a lot of nurses are probably still looking for jobs.”

P

But for a surgical nurse of nearly 40 years, Davis has found that the richness of a career in health care extends beyond what you can learn in a hospital, and how it informs the life that you lead when you’re ready to transition to a new phase.

“I love nursing,” Davis said. “It’s the most rewarding career that anyone can hold. God bless anyone who’s

48 | OR TODAY | DECEMBER 2019

going into the field.”

Growing up in the Bronx, Davis worked at Lincoln Hospital (now Lincoln Medical Center) on Bruckner Boulevard as a teenaged candy striper. She remembers working in a neonatal pediatric area, making beds and taking care of babies. Her mother used to talk to her about nursing because she’d always wanted to be a nurse herself. Those career dreams never came to fruition – mom instead became a caregiver and worked to send money home to her siblings in North Carolina – but after Davis excelled in a health care elective in high school, she started to think more seriously about making a career of it.

She earned her Bachelor of Science in Nursing at

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Hunter College in Manhattan.

The university was affiliated with nearby Bellevue Hospital, the oldest public hospital in the country. After graduating in January 1980, her first assignment was a med-surg unit at Roosevelt Hospital (now Mt. Sinai).

When they weren’t training any new OR nurses, Davis ended up at Beth Israel, now Mount Sinai Beth Israel, two years later. By the end of 2019, she’ll officially retire from that health system, where she’s worked ever since.

After nearly four decades in nursing, Davis has a perspective that spans technological and clinical eras in the field.

“Things were not as advanced as they are now,” she remembers. “We weren’t doing laparoscopic procedures; we weren’t doing robotic procedures. Back then, if you had your gallbladder removed, you had an abdominal incision. That does not happen now. With three ports, your gallbladder can be removed, and you can go home the same day, pain-free.”

Documentation is another key difference. In the 1980s, Davis can remember surgical notes being made much more sparsely; today, data is tracked digitally, from preoperative contact to recovery. In some ways, she worries that these responsibilities take away from staff having more meaningful interactions with patients; relieving anxiety and preparing them for surgery.

These days, Davis has access to a key advancement from years ago: the “time-out” process, which empowers any member of the surgical team to halt any procedure about which he or she has a concern.

Throughout her career, she’s always been a patient advocate, but the time-out policy has helped give her a voice in the room.

Prior to outpatient procedures, staff identify patients by name and vital information, identify themselves and their roles in the procedure, and ask about any patient concerns. If, during the procedure, anyone on the team sees something that’s not correct, they’re obliged WWW.ORTODAY.COM

to stop and call a time-out, and ask, “Can we do something different?” she said. The same happens during debriefing, when staff review procedures, specimen and urine output, equipment malfunctions, and ask whether there’s anything they could’ve done better.

Davis understands the “time-out” as a piece of “a broad spectrum of the whole process,” and as a dedication to continuous performance improvement.

“I think it’s good to have that collaborative effort on all the different crews that are working together,” she said. “You will have the anesthesiologist, the doctor, the resident, the scrub techs, the nurse, and anyone else who’s in the room; the radiologist if the patient has to have an X-ray. All these things are involved in that process because

counterparts to continue to advance their education, and her peers in leadership to continue to support them with the skills and knowledge they’ve developed over the years.

“Anything you can offer a new nurse is going to benefit a patient,” Davis said. “I was an educator and I’m still an educator. I was an assistant head nurse for maybe 30 years; my specialties were urology and robotics. Any nurse that would come into the OR, I would train them in those specialties.”

“I think education is power,” she said. “You don’t have to stop at a BSN; you can go into a Phd.D. Nursing is so diverse, you can do whatever you want and be successful.”

When she finally hangs up her scrubs for the last time, Davis isn’t sure what she’ll do next. In 2005, she earned a legal nurse consultant certificate from Hofstra, so she could pursue risk management or consulting. She has four grandchildren and a mother with whom she is very close, so much of her retirement is already spoken for on the family front.

Davis is also politically minded and plans to organize voters to be registered and make their way to the polls.

“I love life,” she said. “I enjoy people’s company. I enjoy great conversations.

I have a passion for nursing. I’m sorry that I’m leaving the career after 40 years, but I think that it is time for me to go and take care of myself and spend more time with my family.”

“I want to give my hat to a younger nurse; give them a chance,” she said. “Hopefully, somebody’s going to follow in Pamela Davis’s steps: ‘I remember when she taught me this,’ and, ‘I remember when she said you can’t do that.’ That’s hopefully what would become of my legacy in the nursing career.”

“ I THINK EDUCATION IS POWER POWER.” if there’s something that could be done better, you will know about it.”

It’s the same kind of advice Davis said she would give to a younger nurse: make the patient your priority in every circumstance, advocate for their well-being, and don’t hesitate to call out issues of concern.

“The patient is the priority no matter what,” Davis said. “If you see something, say something. If you feel something’s not right, you stand your ground. If you have a gut feeling that something’s not right, you have to seek advice. You’re usually correct that it was not right.”

Although many younger nurses have described having confrontational relationships with their veteran superiors, Davis said she prefers to embrace rather than eat the young. As she prepares to leave the field, she’s telling her younger

DECEMBER 2019 | OR TODAY |

49

OUT OF THE OR fitness

Start with Ankles for Stronger Hips, Knees

By Miguel J. Ortiz ome of us tend to neglect our feet and ankles more than others. There are those who find time to get pedicures or a massage, but that may not be enough. So, how often are we actually taking time to stretch our ankles or taking care of our calves? Neglecting ankle mobility can have a huge effect on how every other joint moves and functions. For example, if you’re not properly pushing off your toes and walk “flat footed”, you will remain “flat footed” and risk proper hamstring and glute development. This can lead to muscular disfunction and potential hip mobility issues. So, let’s take a look at some ways that we can start to reverse the “flat foot” syndrome, mobilize the ankle and take pressure off joints like the knees and hips at the same time.

S

First, let’s start with the bottom of the foot. Regardless of your currently mobility, I think this should be practiced 5 to 10 minutes a day. While

50 | OR TODAY | DECEMBER 2019

seated take a lacrosse or golf ball and gently roll it up and down the bottom of your foot. I recommend doing one at a time so you can concentrate on pressure and loosen up the muscles that tend to have first contact with the ground. When working any tight spots on the foot, try and lessen the pressure but hold the spot longer (about 20 seconds) to ensure quality release and lengthening of the muscle.

Second, standing calf stretches and simple ankle rolls really help blood flow. This will help get you moving and have your ankles feeling good through the day. To save time, try doing this while brushing your teeth or do some small ankle rolls before you get out of bed. Incorporating more standing ankle stretches against a wall before you get ready for the day, or even before exercise, along with some quality foam rolling will relieve some pressure off the knees and hips. Try to spend a total of three minutes or longer on each side when stretching. With each stretch, continue to try and go deeper or hold the stretch longer to have continuous progress.

Third, as you continue to focus on

ankle mobility and stretching your calves, start to also look at your other movement patterns like walking, squatting or even how you go up the stairs. By releasing these tight muscles that are connected to the ankle, we are starting to undo and relax these over active muscles. But that doesn’t mean the work is all done. You want to focus your attention not only on stretching, but also on correcting the improper movement patterns. We do that with proper movement and activity, whether it’s exercise or simply how you walk, focusing on a proper gait cycle and pushing off the toes appropriately is very important.

With every step you take, you have an opportunity to correct your posture, fix your gait cycle, relieve some knee and hip tension. The good news is that a real commitment can have you feeling better in no time.

Miguel J. Ortiz is a personal trainer in Atlanta, Georgia. He is a member of the National Personal Trainer Institute and a Certified Nutritional Consultant with more than a decade of professional experience. He can be found on Instagram at @migueljortiz.

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OUT OF THE OR health EQ factor

Your Brain, Your Emotions and You By daniel bobinski erhaps you’ve heard of the book, 7 Habits of Highly Effective People. In many ways, it paved the road for the field of emotional intelligence, because it provides a framework for self-management and relationship management.

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One of the recommendations in 7 Habits is examining the lens through which we see the world. Why? Because that lens affects everything we see.

Do you believe people are lazy?

Then you’ll subconsciously look for – and see – that behavior. Do you believe people are selfish? You will look for – and see – instances of that, too. People tend to see what they believe. Examining our lens helps us understand ourselves. And, it helps to realize our co-workers each have their own lens.

This phenomenon of people seeing what they believe is called confirmation bias, and I personally believe it is best understood from an emotional intelligence perspective.

To explain, when we’re very young we have no control over the events around us. So, when we’re one or two years old, we merely observe events and experience any emotions that emerge during those events.

Let’s say at the age of one we

52 | OR TODAY | DECEMBER 2019

encounter a snarling, barking dog. If a parent is nearby and displays immense fear about our safety, we receive an emotional imprint of fear. If this scenario is experienced several times, we become emotionally imprinted.

At that age, we have no choice.

Until we reach an age at which we can cognitively reason otherwise, whenever we see a snarling, barking dog, we’ll experience fear.

Once we form a view about something, confirmation bias kicks in quite easily. To quote Shahram Heshmat, writing in Psychology Today: “Once we have formed a view, we embrace information that confirms that view while ignoring, or rejecting, information that casts doubt on it … We pick out those bits of data that make us feel good because they confirm our prejudices.”

Brain chemistry plays a big role in this. When we see something that confirms a belief, the brain’s “reward center” sends signals that make us feel good. But when we see something that conflicts with our beliefs, it’s like our brain flashes a huge neon sign that reads, “Warning! Conflict! No neuropathways exist for this information!

Avoid! Avoid!”

Confirmation biases continue to form even in our adult years. Let’s say you have a creepy, mean, scruffy-

haired boss who always wears a particular brand of shirt, which is always untucked. For several years you endure his obnoxiousness, but every interaction makes you like him less.

Eventually this guy moves away, but two months later, another scruffyhaired person joins the team who wears that exact same brand of shirt, and always untucked. It’s practically guaranteed your first impression of this guy will not be good, even though you don’t know him!

So, what are your biases? If you developed a belief as a result of a strong emotional imprint, it’s hard to consider an opposing point of view, isn’t it? With that, allow me to encourage you to read (or re-read) Covey’s 7 Habits book. It may help you understand the lens through which you see the world.

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.

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OUT OF THE OR health

Smart Eating Habits to Boost Your Well-Being

By EatingWell f you find yourself feeling irritable or sluggish, your diet may need a tune-up. How you eat – and when – can have a huge impact on how you feel. To keep your energy levels up and your mood on an even keel, follow these savvy nutrition tips.

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Start your day with a healthy breakfast. It really is the most important meal of the day. Power up with a serving or two of whole grains, fruit (preferably whole fruit, rather than juice) and a high-protein food, such as low-fat yogurt, cheese or a little lean meat. The carbohydrates (grain and fruit) will kick-start your metabolism and give your brain fuel to function all morning long, and the protein will help you stay satisfied until lunchtime.

Don’t skip meals. Try to eat every four to five hours to provide your body with a constant source of fuel and help prevent the hunger pangs that leave you feeling tired, cranky and ready to devour anything in sight.

Strive for balance. Be sure your meals include lean, high-protein foods and plenty of whole grains, fruits and vegetables. Such foods take longer to digest, keep you satisfied longer

54 | OR TODAY | DECEMBER 2019

and are more likely to keep you feeling energized. Overall, protein should make up 15 percent of your calories, fat should make up 30 percent or less and grains about 55 percent.

Eat more fish. Research suggests that omega-3 fatty acids found in fish may help alleviate the symptoms of some mental disorders. In one study, participants who had lower blood levels of omega-3 fatty acids were more likely to report mild or moderate symptoms of depression. Get your dose of omega-3 fats from foods including oily fish (salmon, mackerel and sardines), ground flaxseeds, canola oil, walnuts and omega-3-fortified eggs.

Get your vitamin Bs. Studies suggest that low blood levels of two B vitamins – folate and vitamin B12 – are sometimes related to depression.

Foods rich in folate include wholegrain breakfast cereals, lentils, black-eyed peas, soybeans, oatmeal, dark leafy greens, beets, broccoli, sunflower seeds, wheat germ and

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oranges. Foods rich in vitamin B12 include shellfish (clams, oysters, crab), wild salmon (fresh or canned), fortified whole-grain breakfast cereal, lean beef, cottage cheese, low-fat yogurt, milk and eggs.

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Hydrate. To stay healthy and feel your best, you need plenty of water throughout the day. Watch for signs of dehydration, such as impatience, difficulty concentrating and impaired physiological performance.

Try to drink eight 8-ounce glasses of water per day. Be aware that diuretics such as caffeinated and alcoholic beverages can contribute to dehydration, so follow them up with a chaser of water! Eating lots of fruits and vegetables will also boost your fluid intake, as they contain substantial amounts of water.

Learn the difference between true hunger and emotional eating. Many people turn to food to suppress negative emotions, such as stress, anger, boredom, sadness or anxiety. Others use food to reward themselves.

Whatever the reason, it’s important to recognize whether you’re eating because you’re hungry or because of some emotional need.

Knowing why you’re eating is the first step in gaining control over your eating habits.

Once you’ve identified the emotional issues that trigger your eating, you can focus on finding more appropriate, nonfood ways to manage them. For instance, try deep breathing or meditation, call a friend or go for a brisk walk.

EatingWell is a magazine and website devoted to healthy eating as a way of life. Online at www.eatingwell.com.

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DECEMBER 2019 | OR TODAY |

55

OUT OF THE OR nutrition

Family Meals and Healthy Eating

By Charlyn Fargo

rowing up, family meals happened every night – despite chores, school activities, homework and my parents’ schedules. Living in the country, it wasn’t an option to run into town for a meal. “Town” was a half-hour away. My parents only went out on an occasional Friday night with a few neighboring friends, and when they did, it was a big deal. We’d stay home with a babysitter and have a TV dinner.

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In my own family, that pattern has been harder to accomplish. Do we work more? Is it just easier to eat out?

Are my kids involved in more activities? I’m really not sure. But I do know it’s worth taking time for family meals.

The goal is to have at least a couple of meals at home together every week.

Seems simple until you map out schedules, but it’s worth the effort.

Here are a few reasons to take time to eat as a family: • There’s clear evidence that meal structure can heavily influence children’s long-term health. Kids

56 | OR TODAY | DECEMBER 2019

and teens who share meals with their family three or more times per week are significantly less likely to be overweight, more likely to eat healthy foods and less likely to have eating disorders, according to a 10-year study on the protective role of family meals in the Journal of Pediatrics.

• With each additional family meal shared each week, adolescents are less likely to show symptoms of depression, less likely to use/abuse drugs and less likely to engage in delinquent acts, according to a study on family dinners and adolescent health in the Journal of Marriage and Family.

• Adolescents who participate in even one or two family meals per week are less likely to be overweight or obese in adulthood than adolescents who never participate in family meals, according to an article in Public Health Nutrition.

• When people cook most of their meals at home, they consume fewer carbohydrates, less sugar and less fat than those who cook less or not at all.

The bottom line? Eating with your family is a healthy thing to do. Make it a priority and your kids’ health will benefit.

Healthy Eating on a Budget My mom was the queen of doing her meal planning based on the grocery store flyer sales. When the flyer arrived in the mail, she would sit down and decide her menu for the week.

Canned vegetables (at 3 for $1) were gathered to make a healthy chili for football season. When a bottom round roast went on sale, she would put it in the slow cooker and use the leftovers in a vegetable soup (using those canned veggies on sale).

I still marvel at her planning skills and flexibility to use whatever was on sale that week. It forced her to be creative and try new recipes.

Here are a few other tips for eating healthy on a budget, gleaned from watching her over the years: • Eat first, shop later. If you go to the grocery store hungry, you’re likely to be an impulse shopper. Mom always went with a list in hand.

• Look at your cupboards first so you

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don’t buy what you already have.

• Think about getting two recipes out of a purchase. Mom would put a whole chicken in the slow cooker for one meal, then use the leftovers for a white chicken chili or chicken quesadilla.

• Shop what is in season when it comes to fruits and vegetables. Mom would often buy extra tomatoes (if we didn’t have enough from our garden) at the farmers market and then turn them into sauce or homemade tomato juice.

• Eat and cook at home instead of going out. Maybe because we lived in the country, going to a restaurant was a big deal and didn’t happen very often.

• Buy items like oatmeal and rice in bulk rather than in instant packets. It’s always cheaper and usually healthier if you add your own ingredients.

• Limit soda and fruit drinks. Choose milk or water from the tap.

• Limit chips, cookies and high-calorie foods that are high in fat, sodium and sugar. If we had a cookie, it was because Mom made it from scratch.

Try a meatless meal every now and then. Meat is usually the biggest expense. Try substituting kidney, pinto, black or other beans, or eggs when they’re on sale.

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

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57

OUT OF THE OR

Recipe

recipe

Chocolate-Peppermint Shortbread For the shortbread: • 1/2 cup (1 stick) unsalted butter, cut into cubes • 1/2 cup dark brown sugar • 1 teaspoon pure vanilla extract • 1/4 teaspoon salt • 1 cup all-purpose flour For the topping: • 1 cup bittersweet chocolate chips • 1 cup crushed candy canes • 1 cup candied walnuts

the

58 | OR TODAY | DECEMBER 2019

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

Chocolate Peppermint Shortbread is a Holiday Favorite hocolate and peppermint is a flavor combination that’s hard to top. It’s a delicious pairing in a number of desserts such as mousses, ice cream and cake. So for the holiday season, why not put this classic combo in a crumbly cookie like shortbread? No one can ever get enough of these holiday cookies, which shows what a crowd-pleaser they are. Best of all, the shortbread is not hard to prepare.

This time of year, it’s easy to find candy canes for the topping. But for the best red color, look for candy canes that have bright red striping. Round peppermint candies have a larger proportion of white compared to red. I found that out the

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hard way when my cookies looked white with just a tiny hint of red.

I crush the candy canes in a zip-top bag, banging down on it with a heavy saucepan until the candy looks coarsely crushed so you can see the colors. If you want to make a few batches, it’s best to use two 8-inch pans rather than one larger one.

Since the cookies are quite rich, small squares are the perfect serving size. And they look fun and festive on a white platter. Simple to prepare and serious in flavor, these cookies are my final farewell to the holidays. Consider these for your Christmas Eve, New Year’s Eve or New Year’s Day celebrations.

Chocolate-Peppermint Shortbread Makes 16 squares 1. Preheat the oven to 350 F. Line an 8-inch square baking pan with a piece of foil long enough to press up the sides of the pan, leave a 1-inch overhang so you can pull the shortbread out in one piece.

2. To make the shortbread: Melt the butter in a medium saucepan on medium heat. Remove from the heat and add the brown sugar and vanilla extract, stirring until smooth.

Add the salt and the flour, incorporating them gradually and stirring until thoroughly mixed. Spread the mixture into an even layer on the bottom of the prepared pan.

Bake for about 20 minutes, or until the shortbread is golden brown.

3. To add the topping: Remove the shortbread from the oven and sprinkle the chocolate chips over the hot shortbread. Return the shortbread to the oven for 1 to 2 minutes, or just until the chocolate has softened. Remove from the oven and spread the chocolate evenly with a metal spatula. Sprinkle the candied walnuts evenly over the chocolate.

4. Place the pan on a wire rack and cool the shortbread slightly for 20 minutes. Then transfer the pan to the refrigerator to cool for about 40 minutes, or until the chocolate has hardened. Lift the shortbread out of the pans and cut into 16 pieces with a serrated knife. Arrange on a platter and serve.

Make ahead: The cookies may be prepared up to one month ahead and stored in an airtight container in the freezer. Defrost at room temperature for about 15 minutes before serving. They may also be kept up to three days in airtight container at room temperature or in the refrigerator.

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DECEMBER 2019 | OR TODAY |

59

OUT OF THE OR pinboard

OR TODAY

• CONTEST • DECE MBE R

TAKE YOUR BEST Email us a photo of yourself or a colleague reading a copy of OR Today and you could win a $25 Bath & Body Works gift card!

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

YOU could be the next winner!

The Winner Gets a $25 Bath & Body Works Gift Card!

her we can do for each ot g in th st be e th , ss re "In times of st ts and to be assured ar he r ou d an rs ea r is to listen with ou ers." important as our answ as st ju e ar ns tio es qu that our - Fred Rogers

OR TODAY THIS MONTH'S CONTEST WINNER Submitted by:

Barbara Gibson, NOR RN, C , N S B son, ra Gib Barba

60 | OR TODAY | DECEMBER 2019

BSN, RN, CNOR

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The News and Photos

that Caught Our Eye This Month

OUT OF THE OR pinboard

AUTHOR SHARES MESSAGE OF ‘RADICAL KINDNESS’ In 1968 Fred Rogers revolutionized the world of children’s television and taught generations that the best thing we can do is to be kind to ourselves and one another. For Angela Santomero, Fred Rogers’ kindness led her to a career in children’s television, where she created legendary shows such as “Blue’s Clues” and “Daniel Tiger’s Neighborhood.” Now in “Radical Kindness: The Beauty and Benefits of Giving and Receiving” Santomero is teaching everyone – regardless of age – how to practice radical kindness.

What is radical kindness? More than just “treating others the way you want to be treated” radical kindness is “being unconditionally kind all the time to everyone. It means going beyond situational niceness or just doing the right thing and, instead, living from a place of compassion,” says Santomero. This type of radical kindness not only helps us see the world as a

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better place, but makes us overall happier, healthier people.

She explores how radical kindness begins within, as we must first learn to be kind to ourselves, a key component of self-care.

This means listening to all the voices in our head in order to realize the difference between what we want and what we really need. It also means asking for help when we require it – after all, if we cannot manage that, how can we give it in return? Her second step to radical kindness is being kind to others; waiting before passing judgment on someone else, actively listening with full attention and using compassion to dissolve conflict rather than reacting. Once we have achieved being radically kind to ourselves and to others we can work to make the world a better place, one small act a time.

DECEMBER 2019 | OR TODAY |

61

INDEX

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ALPHABETICAL Action Products, Inc.……………………………………… 23

C Change Surgical……………………………………………… 6

MD Technologies Inc.………………………………… 40-43

AIV Inc.……………………………………………………………… 55

Cygnus Medical…………………………………………………… 9

MedWrench……………………………………………………… 53

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

Doctors Depot…………………………………………………IBC

Microsystems……………………………………………………… 5

Arthroplastics, Inc.…………………………………………… 27

Ecolab Healthcare…………………………………………15,28

OR Today Webinar Series……………………………… 24

ASCA………………………………………………………………… 57

Healthmark Industries Company, Inc.……… 4,21

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

Avante Patient Monitoring…………………………………51

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

Tetra Medical Supply Corp.…………………………… 23

ANESTHESIA

MD Technologies Inc.………………………………… 40-43

PRESSURE ULCER MANAGEMENT

Doctors Depot…………………………………………………IBC

GENERAL

Action Products, Inc.……………………………………… 23

ASSET MANAGEMENT

AIV Inc.……………………………………………………………… 55

REPAIR SERVICES

Microsystems……………………………………………………… 5

HOSPITAL BEDS/PARTS

Avante Patient Monitoring…………………………………51

ASSOCIATION

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

Cygnus Medical…………………………………………………… 9

ASCA………………………………………………………………… 57

INFECTION CONTROL

CARDIAC PRODUCTS

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

REPROCESSING STATIONS

C Change Surgical……………………………………………… 6

Cygnus Medical…………………………………………………… 9

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

Healthmark Industries Company, Inc.……… 4,21

SAFETY

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

Healthmark Industries Company, Inc.……… 4,21

Cygnus Medical…………………………………………………… 9

INSTRUMENT STORAGE/TRANSPORT

SINKS

Healthmark Industries Company, Inc.……… 4,21

Cygnus Medical…………………………………………………… 9

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

CATEGORICAL

CARTS/CABINETS ALCO Sales & Service Co.……………………………… 57

CS/SPD

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

Doctors Depot…………………………………………………IBC

STERILIZATION

MD Technologies Inc.………………………………… 40-43

INSTRUMENT TRACKING

Microsystems……………………………………………………… 5

Microsystems……………………………………………………… 5

Healthmark Industries Company, Inc.……… 4,21

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

MONITORS

MD Technologies Inc.………………………………… 40-43

DISINFECTION

Avante Patient Monitoring…………………………………51

SURGICAL

Cygnus Medical…………………………………………………… 9

Doctors Depot…………………………………………………IBC

MD Technologies Inc.………………………………… 40-43

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

ONLINE RESOURCE

SURGICAL INSTRUMENT/ACCESSORIES

DISPOSABLES

MedWrench……………………………………………………… 53

C Change Surgical……………………………………………… 6

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

OR Today Webinar Series……………………………… 24

Cygnus Medical…………………………………………………… 9

Tetra Medical Supply Corp.…………………………… 23

OR TABLES/BOOMS/ACCESSORIES

Healthmark Industries Company, Inc.……… 4,21

ENDOSCOPY

Action Products, Inc.……………………………………… 23

TELEMETRY

Cygnus Medical…………………………………………………… 9

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

AIV Inc.……………………………………………………………… 55

Healthmark Industries Company, Inc.……… 4,21

OTHER

Avante Patient Monitoring…………………………………51

MD Technologies Inc.………………………………… 40-43

AIV Inc.……………………………………………………………… 55

TEMPERATURE MANAGEMENT

PATIENT MONITORING

C Change Surgical……………………………………………… 6

AIV Inc.……………………………………………………………… 55

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

WASTE MANAGEMENT

Avante Patient Monitoring…………………………………51

Arthroplastics, Inc.…………………………………………… 27

FLUID CONTROL

POSITIONING PRODUCTS

MD Technologies Inc.………………………………… 40-43

Arthroplastics, Inc.…………………………………………… 27

Action Products, Inc.……………………………………… 23

WOUND MANAGEMENT

FLUID MANAGEMENT

Cygnus Medical…………………………………………………… 9

Tetra Medical Supply Corp.…………………………… 23

Ecolab Healthcare…………………………………………15,28

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

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

FALL PREVENTION

62 | OR TODAY | DECEMBER 2019

Cygnus Medical…………………………………………………… 9

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• Includes Ventilator modes: Pressure Support, SIMV, Volume and Pressure Control.

• 7100 Ventilator features volume and pressure control modes with Electronic PEEP.

• Can be integrated with your hospital information system.

• Heated Absorber

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• Low circuit volume contributes to a fast response well suited for low flow cases - 2.7 L in vent mode, 1.2L in manual mode.

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Designed by an Anesthesiologist

who understands patient and surgeon needs Enhanced Humbles LapWrap® Positioning Pad

Loop the LapWrap® tab around the side rail of the OR table.

The LapWrap’s® tab configuration also makes positioning bariatric patients easier.

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Now you can secure your patient in place.

Designed to prevent tissue injury. Arms stay where you put them during the procedure.

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Adaptable to all size patients.

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Keep arms securely positioned.

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Anesthesiologist Frank Humbles, M.D. knows the importance of patient positioning. The Enhanced Humbles LapWrap®.

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The LapWrap® was designed to meet AORN recommendations in “Recommended practices for positioning the patient in the perioperative practice setting” to prevent tissue injury and ischemia that may be caused by tucking a patient’s arms at his or her side.

imp® products are protected by patent & patent pending rights ~ go to impmedical.com/patents AORN is a registered trademark of AORN, Inc. AORN does not endorse any commercial company’s products or services.

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