OR Today - January 2020 by MD Publishing

PRODUCT FOCUS ENDOSCOPES

CE ARTICLE BARIATRIC SURGERY UPDATE

LIFE IN AND OUT OF THE OR

OUT OF THE OR HEALTH TRENDS

EQ FACTOR THE ROLE OF FEAR IN CONFLICT RESOLUTION

JANUARY 2020

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ANTIMICROBIAL

STEWARDSHIP Perioperative Professionals Play Critical Role

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OR TODAY | January 2020

contents features

ANTIMICROBIAL STEWARDSHIP PERIOPERATIVE PROFESSIONALS PLAY CRITICAL ROLE Antimicrobial agents are critical to destroying or severely inhibiting the growth of pathogenic microorganisms. Since antibiotics are given preoperatively in hospital operating rooms and ambulatory surgery centers as part of SSI prevention, it’s critical for hospitals and ASCs to create an antimicrobial stewardship program (ASP).

AORN OF MIDDLE TENNESSEE FUNDRAISER A HIT The fifth annual Healing Hands Helping Heroes Casino Night raised an estimated $30,000 to benefit the AORN of Middle Tennessee and REBOOT Combat

Several research firms predict that the global endoscopy devices market will continue to expand. A growing preference for minimally invasive endoscopic procedures and an increase in the prevalence of certain diseases are factors contributing to market growth.

The goal of this continuing education program is to provide nurses, occupational therapists, and physical therapists with an overview of the care of patients who have undergone bariatric surgery.

MARKET ANALYSIS

CE ARTICLE

Recovery.

OR Today (Vol. 20, Issue #1) January 2020 is published monthly by MD Publishing, Inc. 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. © 2020

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10 News & Notes 19 CCI: Looking to the Future 20 IAHCSMM: Point-of-Use Care: The OR’s Role in Safe, Effective Device Processing 22 Webinar Recap: UVC Disinfection Presentation Delivers ‘Excellent Overview’ 24 AORN of Middle Tennessee Fundraiser a Hit

ACCOUNTING Diane Costea

IN THE OR 27 Market Analysis: Endoscopy Market Reaches New Highs 28 Product Focus: Endoscopes 32 CE Article: Bariatric Surgery Update

OUT OF THE OR 44 Spotlight On 46 Fitness 48 Health 51 EQ Factor 52 Nutrition 54 Recipe 56 Pinboard

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INDUSTRY INSIGHTS

news & notes

Healthmark Makes Clinical Education Appointments Healthmark Industries has announced the appointment of former Clinical Education Director Stephen Kovach to clinical education emeritus. Healthmark Industries also announced the promotion of Mary Ann Drosnock, MS, CIC, CFER, RM (NRCM), FAPIC to director of clinical education and added Kevin Anderson as a new cliniKovach cal education coordinator. “Steve has been a vital element to our success at Healthmark over the years and we can’t thank him enough for his years of service,” says Vice President Ralph Basile. “In his new role as clinical educator emeritus, Steve will continue to play a vital role in our continued success.” Drosnock Kovach has been in the hospital field for over 44 years. He started his career as a sterilization orderly in 1975. He has a bachelor's degree from Central Michigan University, with a major in biology and history. He is active on the state and national levels of various organizations having held many positions. He was the educational chair for AORN Specialty Assembly for SP/MM (2006-2010). This was a volunteer position. He is a voting member on various AAMI committees. He also has been an instructor at the community college level and published many articles varying in subject matter from perfusion to the importance of cleaning surgical instruments. Many of his articles are available online at www.cpdguy. net. He has also authored chapters in both the IAHCSMM 7th technical manual and the management manual. Kovach received the IAHCSMM Award of Honor for his dedication to improving the role central service plays in the hospital. He also was named by Hospital Purchasing News in 2007 as one of the 30 most influential people within the field of central service. He is very proud to say he has

10 | OR TODAY | JANUARY 2020

“worked in central service the heart of hospital” and he is just as proud to say “he works for Healthmark Industries the company that services the people who work in the heart of the hospital.” “Mary Ann has been a key part of our success and we are thrilled to promote her to this important position,” says Basile. “I am honored to accept this position and together with my team of clinical educators, I look forward to continuing to promote proper processing of medical devices to prevent infections,” says Drosnock. Drosnock joined Healthmark in 2015 as the clinical education manager for endoscopy. Before joining Heathmark, Drosnock was responsible for management of the infection control program and device reprocessing functions for Olympus America, including Canada and Latin America. In this role, she had responsibility for the development of position statements and policies regarding device compatibility, and health and safety information related to device utilization and reprocessing. Earlier in her career, she worked for 9 years in the pharmaceutical industry in a supervisory capacity as a microbiologist in both quality control and research and development. Immediately following this role, she moved on to be an adjunct professor of microbiology at a local college. In 1999, Drosnock received a B.S. in biology from Albright College and in 2006 she received a master’s degree in medical device and pharmaceutical quality assurance and regulatory affairs from Temple University. She has also obtained certifications in both drug development and pharmaceutical science from Temple University. In 2011, she received her certification in infection control through APIC and the Certification Board of Infection Control (CBIC). In 2012, Drosnock received her certification as a Flexible Endoscope Reprocessor (CFER) through the Certification Board of Sterile Processing (CBSPD). In 2013, she attained the status of Nationally Certified Registered Microbiologist (RM [NCRM]). •

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INDUSTRY INSIGHTS

ECRI Institute: Diagnostic Tests, Medication Pose Risks to Patients New research from ECRI Institute reveals that diagnostic testing and medication events are the most frequent safety risks patients face in ambulatory care. ECRI Institute’s "Deep Dive: Safe Ambulatory Care, Strategies for Patient Safety & Risk Reduction" identifies solutions for five key types of safety challenges occurring in ambulatory care, the largest and most widely used segment of the health care system. ECRI Institute analyzed 4,355 adverse events reported by physician practices, ambulatory care centers and community health centers between December 2017 and November 2018. Nearly half of the events involved diagnostic

news & notes

testing errors; a quarter involved medication safety; the rest involved falls; security and safety; and privacy-related risks. “As health care delivery shifts from hospitals to ambulatory care settings, it can be challenging to coordinate care among various clinicians, systems, and facilities, raising the potential for errors that put patients at risk,” said Marcus Schabacker, MD, PhD, president and CEO of ECRI Institute. “Reducing and eliminating adverse events in an outpatient environment will require an unprecedented commitment to collaboration and coordination.” • For more information, visit ECRI.org.

Masimo Announces CE Marking of Radius Capnography for the Root Patient Monitoring and Connectivity Platform Masimo has announced that Radius Capnography, a portable real-time capnograph with wireless Bluetooth connectivity, has received CE marking. Radius Capnography connects with the Root Patient Monitoring and Connectivity Platform to provide seamless, tetherless mainstream capnography for patients of all ages. Radius Capnography is the second wireless sensor created by Masimo, joining Radius PPG, or Radius Photoplethysmography, the first tetherless sensor solution to offer Masimo SET Measurethrough Motion and Low Perfusion pulse oximetry. Radius Capnography requires no routine calibration and minimal warm-up time, with fully accurate EtCO2 and respiration rate measurements and continuous EtCO2 waveforms displayed within 15 seconds. Root is a hub that integrates an array of technologies, devices and systems to provide multimodal monitoring and connectivity solutions. Root’s plug-and-play expansion capabilities allow clinicians to simultaneously monitor with Radius Capnography and other measurements, such as Radius PPG SET Measure-through Motion and Low Perfusion pulse oximetry and advanced rainbow Pulse CO-Oximetry measurements, for expanded visibility of patient status.

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Joe Kiani, founder and CEO of Masimo, said, “We’re happy to introduce the second tetherless, cableless sensor for Root, Radius Capnography. With this CE marking, the advanced connectivity of Radius Capnography is now available in both the U.S. and CE-marked countries, bringing the power of Masimo capnography to even more hospitals around the world.” •

JANUARY 2020 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

OxyCide Daily Disinfectant Cleaner Receives U.S. EPA Candida auris Claim Ecolab Inc. has received U.S. Environmental Protection Agency (EPA) approval for its OxyCide Daily Disinfectant Cleaner for efficacy against Candida auris (C. auris), an emerging fungal pathogen that presents a serious global health threat. “C. auris is an increasing risk, and is one of 34 different organisms that can be killed through the use of OxyCide Daily Disinfectant Cleaner,” said Christopher Smith, Ecolab senior vice president and general manager for healthcare in North America. “Hospitals throughout the country are realizing the benefits of using OxyCide within their facilities.” OxyCide Daily Disinfectant Cleaner is an EPA-registered one-step disinfectant cleaner, virucide and deodorizer with sporicidal activity designed for daily hospital use on flexible and hard non-porous surfaces. When used as directed, it is proven effective in preventing healthcare-associated infections (HAIs); killing C. auris in three minutes as well as Clostridioides difficile (C. diff) and 32 other organisms in five minutes or less. Designed for daily, discharge and isolation cleaning, OxyCide Daily Disinfectant Cleaner enables product standardization and workflow simplification by replacing multiple products with one solution. The diluted product, when used according to label instructions, requires no personal protective equipment (PPE). OxyCide Daily Disinfectant Cleaner's active ingredients hydrogen peroxide and peracetic acid provide favorable material compatibility that helps minimize damage to surfaces, including stainless steel, computer screens, mattresses and blood pressure cuffs. It does not leave residual films or salts behind, require rinsing or bleach fabrics. The OxyCide Daily Disinfectant Cleaner claim against C. auris is currently being reviewed by state agencies, including the California Department of Pesticide Regulation (CDPR). •

12 | OR TODAY | JANUARY 2020

Philips Launches Next-Generation Vital Signs Monitor Royal Philips has announced the debut of EarlyVue VS30, a new vital signs monitor, in the U.S. Expanding on Philips’ General Care solutions portfolio, Philips EarlyVue VS30 uses automated Early Warning Scoring (EWS) to collect critical vital signs and calculate risk-based alerts that allow clinicians to identify subtle signs of patient deterioration. With this point-of-care alert capability, clinicians in general care settings can facilitate communication between caregivers for timely intervention and patient care. With its connectivity capability, the EarlyVue VS30 monitor allows clinicians to view vitals at the bedside or remotely through a new monitor-to-monitor data sharing feature. Designed to create new workflow efficiencies, the VS30 captures patient data and securely transmits it directly into the hospital’s EMR to help reduce errors and support gap-free patient records to help improve patient outcomes. “With preventable patient adverse events and clinical workflow issues on the rise, it’s imperative that the health care industry looks for ways to alleviate these challenges,” said Peter Ziese, business leader of monitoring and analytics at Philips. “Integrated technology with smart algorithms, like EarlyVue VS30, can benefit both clinicians and patients by limiting transcription errors and providing early risk-based alerts for timely interventions – allowing clinicians to, confidently and proactively deliver care.” The EarlyVue VS30 monitor has received 510(k) clearance from the FDA and is available for sale in the U.S. •

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PolyPid Announces Positive Results PolyPid Ltd. announced positive top-line results from its Phase 2 clinical trial evaluating D-PLEX100 for the prevention of surgical site infections (SSI) in abdominal surgery. The Phase 2 clinical trial enrolled 201 patients and is a prospective, multicenter, randomized, controlled, single-blind, two arm study to assess the safety and efficacy of D-PLEX100 administered concomitantly with the Standard of Care (SoC), compared to the SoC control arm, in the prevention of surgical site infection (superficial and deep) in patients undergoing abdominal surgery. The primary endpoint is the infection rate as measured by the proportion of subjects with an SSI event within 30 days post-surgery. Mortality within 30 days was considered as treatment failure. In the Intent to Treat (ITT) population, the local administration of D-PLEX100 resulted in a statistically significant decrease in SSIs of 57 percent, compared to SoC alone (p<0.0136). In the Per Protocol population (n=179), which includes all ITT subjects who completed the study without any major protocol deviations, patients treated with D-PLEX100 achieved a statistically significant decrease in SSIs of 68 percent, as compared to SoC alone (p<0.0024). Within the first 60 days post-surgery, there were five deaths in the SoC treatment arm, as compared to zero in the D-PLEX100 treatment arm. In addition, there were no D-PLEX100-related serious adverse events. “This was a robust clinical trial in one of the most complex surgical setting for SSIs, abdominal surgery with colorectal resection,” said Prof. Aviram Nissan, M.D., head of the department of general and oncology surgery at Sheba Medical Center and clinical investigator for the Phase 2 trial. “The vast majority of the patients in the study had colorectal cancer, making the results of this study especially impressive. I look forward to further evaluating D-PLEX100 in a Phase 3 clinical trial.” “We are extremely pleased with the totality of these top-line data, which represent our first results for D-PLEX100 from a large, blinded, prospective clinical trial designed with FDA input,” said Amir Weisberg, PolyPid’s CEO. “Based on these compelling results, we intend to conduct an end of Phase 2 meeting with the U.S. Food and Drug Administration (FDA). Following our interactions with the FDA, we expect to be in a position to submit an Investigational New Drug (IND) amendment to conduct a Phase 3 trial for the prevention of post-abdominal SSIs. This would be the second surgical model for D-PLEX100 to enter Phase 3. In our most advanced clinical program for D-PLEX100, for the prevention of post-cardiac surgery sternal infections, we expect the first patient in our Phase 3 trial to be enrolled before year-end.” •

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news & notes

FDA Clears Duodenoscope Protective Device GI Scientific LLC announced that the U.S. Food and Drug Administration (FDA) cleared its ScopeSeal Duodenoscope Protective Device, the first endoscopic shield for protecting the distal end of a duodenoscope from contamination during ERCP procedures. ScopeSeal is a single-use disposable infection control device that preserves duodenoscope optics and other key functionality while sealing the infection prone distal end of the Olympus duodenoscope used in endoscopic retrograde cholangio-pancreatography (ERCP) procedures. ScopeSeal is the only device cleared for human use by the FDA that seals the elevator area of the scope and significantly reduces duodenoscope distal end contamination during use. “It is very difficult to consistently clean and disinfect duodenoscopes between patients because of the intricate moving parts at the distal end of these advanced technology

instruments. This is true regardless of whether high-level disinfection or terminal sterilization is used to reprocess. Buildup of bacteria and other biomatter in recessed areas on these scopes between patients is almost certainly the cause of recent outbreaks. The best way to truly prevent difficult-to-remove contamination at the distal end of the scope is to protect against contamination in the first place, by sealing the distal end, which is exactly what ScopeSeal does. I am excited and relieved that the FDA cleared this device. It will be a game-changer for ERCP infection prevention, complementing existing hospital investments in advanced technology duodenoscopes and sophisticated scope reprocessing,” said Romney Humphries, former section chief, clinical microbiology, UCLA Medical System and current clinical professor of pathology, University of Arizona. •

Report: ASC Market to Eclipse $50 Billion The “2019 Ambulatory Surgery Center Market Report – United States” has been added to ResearchAndMarkets. com’s offering. The ambulatory surgery center (ASC) market is estimated to grow up to $55 billion by 2025. ASC executives continue to rank improved surgical capabilities as the primary driver of growth; however, they also cite the aging U.S. population and increased surgical capacity as contributors. In 2017, 5,603 Medicare-certified ASCs treated over 3.4 million Medicare fee-for-service (FFS) beneficiaries. The majority of ASCs (93.8%) are for profit, with 3.5% considered nonprofit and 2.7% are government owned. The majority of ASCs are physician-owned and report no affiliation with a hospital or health system. In 2018, these physicians reported ASC ownership as more appealing than being employed by a hospital. Reimbursement initiatives from private payers boost this perception. They are currently offering ASC physicians higher reimbursement rates, and are also offering bonuses for each patient that receives care in an ASC rather than in hospital outpatient departments (HOPD). ASCs continue to perform more than half of all U.S.

14 | OR TODAY | JANUARY 2020

outpatient surgical procedures and are expected to see greater volumes as the number of outpatient procedures increases by an estimated 15% by 2028. Though these increases will be experienced by both ASCs and HOPDs alike, ASCs are poised to receive an outsized portion of volume growth. From 2015 to 2022, the proportion of outpatient cases performed in ASCs is expected to increase across most service lines with the largest jump (10%) to occur in spine procedures. Among other factors, consumerism is set to play a major role in driving ASC volume increases, as procedures performed in ASCs cost an average of 58% less than the same procedure in an HOPD. Payers and patients alike, in an effort to reduce costs and increase value, are driving the shift in procedures from high-cost HOPDs to more costeffective ASCs. While reimbursement continues to be lower in ASCs when compared to HOPDs, they are able to drive profits through efficiency. Lower average operating room turnover time and growing patient volumes bring in greater revenues while lower operating expenses broaden margins. For the average ASC, 2018 operating expenses were 67% of net revenue; in hospital outpatient departments this figure was 97%. •

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Integrated Endoscopy Launches of NUVIS Single-Use Arthroscope Integrated Endoscopy, a medical device company pioneering the development of high-definition, low-cost single-use endoscopes for the arthroscopic surgery market, announced it has begun the international pilot launch of its NUVIS (pronounced “nuvee”) Single-Use Arthroscope technology via placement in centers of medical excellence around the world. News of the international roll out comes on the heels of Integrated Endoscopy’s clearance from the Food and Drug Administration (FDA) to market NUVIS, a first-ofits-kind endoscope designed for use in arthroscopic surgical procedures, in the United States. NUVIS is a battery-operated arthroscope that is designed to provide high-definition visualization via a proprietary optical design, while directly addressing key safety and sterility issues associated with traditional, reusable arthroscopes. The single-use nature of the technology provides surgeons with an affordable way to eliminate bio-burden and risk of infection and disease transfer due to lapses in instrument reprocessing; eliminates the need for the traditional light source and the associated heat; and can be used on existing video systems in the marketplace. As part of this global strategy, Integrated Endoscopy has been working with a number of key hospitals and surgeons around the world, introducing the NUVIS technology. Among the early adopters globally are various centers located in the United Kingdom, France, India, Australia and a number of locations in the U.S. “The NUVIS scope is an innovative and disruptive concept that enhances the surgeon’s experience by eliminating the light cord, which contributes to the clutter on the field and is a source of contamination and heat,” said David S. Bailie, MD, president of the Arizona Institute for Sports Knees and Shoulders LLC. “The scope helps to improve efficiency in the OR by eliminating waiting or downtime associated with current reusable scopes when defective, damaged or scratched. The image quality is on par with any conventional scope I have used and the single-use packaging ensures a sterile product on every case. This product enhances our existing equipment and adds value to the everyday processes in the surgery center.” “We’re excited to be sharing our NUVIS technology with surgery thought leaders around the world,” said Brad Sharp, Integrated Endoscopy’s CEO. “The response has been overwhelmingly enthusiastic, and it’s gratifying to be able to provide the international surgical community a technology we believe will be a superior, less expensive and safer new gold-standard in arthroscopic surgery. With NUVIS, we can provide surgeons with an out-of-the-box, battery-operated, single-use endoscope with high-definition image quality at a price point well below that of reusable scopes. Couple that with our patented, low temperature, embedded LED light source, and we believe we can significantly impact a global market opportunity that exceeds $4 billion.” Sharp added that Integrated Endoscopy’s NUVIS arthroscope is now available to various select markets around the world, with plans of full global availability by early 2020. With over 16 million arthroscopic procedures worldwide, the NUVIS single-use arthroscope represents a significant opportunity for the company while improving efficiency and safety and reducing costs in operating rooms and surgery centers worldwide. •

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MemorialCare Long Beach Medical Center Utilizes ExcelsiusGPS The Spine Center at MemorialCare Long Beach Medical Center has acquired an ExcelsiusGPS system, a robotic navigation technology that elevates precision in spine surgeries. Long Beach Medical Center is the only hospital in L.A. County offering this technology for spine surgery. Spine surgeons at Long Beach Medical Center who are trained to use the technology can now perform back and spine procedures that may result in faster recovery, less blood loss and muscle damage. ExcelsiusGPS is designed to improve accuracy and optimize patient care by using robotics and navigation, much like a GPS in your car. This revolutionary robotic navigation system provides less invasive surgical options for several complex spinal, orthopedic and neurological conditions. “This state-of-the-art robotic navigation platform acts as an assistant for the surgeon and can improve outcomes for people suffering from degenerative disc disorders or

16 | OR TODAY | JANUARY 2020

traumatic spinal injuries,” says Philip S. Yuan, M.D., board-certified orthopedic surgeon, Spine Center, Long Beach Medical Center. “The robotic arm aligns tools along a planned pathway, improving accuracy of screw placement and ultimately optimizing patient care.” ExcelsiusGPS provides improved visualization of patient anatomy through the procedure to help optimize patient treatment. The system is designed to streamline the surgical workflow and reduce radiation exposure to surgeons and staff. “This revolutionary robotic navigation platform created by Globus Medical Inc. is the world’s first technology to combine a rigid robotic arm and full navigation capabilities into one adaptable platform for accurate trajectory alignment in spine surgery,” according to a press release. “At Long Beach Medical Center, we are committed to providing the highest quality of care for our patients. As a spine surgeon, I look forward to the exciting opportunities and impact that ExcelsiusGPS is already having in the field of spine surgery, robotics and navigation,” Yuan adds.

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CCI news & notes

Looking to the Future By James X. Stobinski, PhD, RN, CNOR, CSSM (E) he Competency and Credentialing Institute (CCI) will again attend the AORN Surgical Conference and Expo in 2020 to be held in Anaheim, California. This event is a welcome opportunity for us to connect with our certified nurses. The theme of our education offering will be “The Future of Credentialing.” The last two years in our education sessions we have concentrated on the more immediate issue of the upcoming changes to the CNOR recertification methods. That transition is now well underway and it is now time to look further forward in the broader field of credentialing.

What credentialing and certification will look like in the near future is a topic of much discussion at CCI and this issue was recently the focus of our strategic planning efforts. This topic will be explored in some detail in Anaheim and we welcome the input of our stakeholders at that venue. I would like to take the opportunity of this column to share some of what perioperative nurses can soon expect from CCI. An increasing amount of surgery in U.S. health care is now performed on an ambulatory basis. Relatively complex spine and joint procedures, which were formerly the exclusive domain of the hospital setting are done increasingly in the ambulatory setting. In response to this clear trend CCI will launch our fourth credential in the year 2020. The new credential, CNAMB, will concentrate on the unique role of nurses working in the WWW.ORTODAY.COM

ambulatory setting. Registration for this credential will begin in February with the first test administered in April of 2020. Those interested in receiving more information on this certification may notify CCI by submitting their contact information on the CCI website. CCI often receives inquiries regarding subject areas for educational offerings and new credentials. Nurses have expressed interest in educational offerings and materials in a diversity of subjects, but they have also requested more flexibility in the delivery of these resources. In response to these requests, CCI will begin a new credentialing offering later this year with the start of our microcredentials program. This program launched in December with the Strategic Management microcredential. As defined on the GettingSmart website micro-credentials indicate, “ … demonstrated competency in a specific skill. Micro-credentials are also on-demand, shareable and personalized. Learners have voice and choice in what credentials they want to pursue and can create their own education playlists.” (Ryerse, 2017). CCI, through the investment in the LearnUpon learning management system, can now provide this educational offering including a digital badge documentation upon completion. More micro-credentials will be forthcoming in 2020 as CCI leverages partnerships to expand the learning and credentialing options of perioperative nurses. I would also like to announce that CCI has recently added a fourth staff member to our credentialing team. We are now fully staffed. Previously, your

first contact with CCI would be with a customer experience representative. CCI will now transition to a higher level of service using staff specifically trained in specialty nursing certification. Consistent with our views on Continuous Professional Development (CPD) for perioperative nurses this team will receive role specific training, be enrolled in a career path and be offered the opportunity to attain certification in their field. CCI is very excited to make available the CNAMB credential and microcredentials. We believe the investment in our staff will result in more consistent service for our certificants and is consistent with our commitment to the nursing profession. We welcome the opportunity to discuss these topics with you in Anaheim.

References: Ryerse, M. (2017). Competency-Based Micro-credentials are Transforming Professional Learning. Accessed November 10th 2019 at: https://www. gettingsmart.com/2017/11/micro-credentialstransforming-professional-learning/

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. JANUARY 2020 | OR TODAY |

INDUSTRY INSIGHTS

IAHCSMM

Point-of-Use Care: The OR’s Role in Safe, Effective Device Processing By Julie Williamson terile Processing (SP) professionals’ critical core responsibility is the processing of instrumentation and the delivery of clean, high-level disinfected or sterilized devices that are well functioning and ready for patient use in the operating room and other patient care areas. It’s important to point out, however, that SP professionals also rely on their health care customers (including and especially their operating room and endoscopy team members) to do their part in this quest for safe, effective instrument care.

Specifically, they need end user departments to commit to proper point-of-use care – a vital step that is often missed in many health care facilities, and a crucial practice clearly outlined in the latest regulatory guidelines and industry standards, including those from the Association of periOperative Registered Nurses (AORN), the Association for the Advancement of Medical Instrumentation (AAMI) and the Association of Surgical Technologists (AST). In some cases, OR team members and professionals in other patient care areas may not be fully aware of the latest standards and guidelines – or even facility procedures – that address point-of-use care; therefore, they may lack a solid understanding of its essential role in patient and employee safety, and in more efficient, effective instrument reprocessing. In other cases, facility policy may not be adequately disseminated and enforced, and some

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professionals in high-pressure procedure areas like the OR may fail to engage in proper point-of-use care practices due to time constraints. Make no mistake, failure to consistently implement proper point-of-use care can spur negative outcomes that not only impact health care departments, but patients themselves. Delicate and sophisticated instruments can become damaged, leading them to malfunction at the point of patient care and generate extensive and costly repairs (or the need for premature replacement, which is even costlier). Improperly transported contaminated devices may also jeopardize employee, patient and visitor safety. Further, bioburden and fluids that are allowed to dry on devices after their use pose another serious risk because it makes cleaning and reprocessing more difficult, which increases the risk of a contaminated device being used on a subsequent patient.

Teamwork is critical Regulations and evidence-based standards and guidelines across multiple organizations align on the importance of providing proper point-of-use care and transport of contaminated reusable items – and, more than ever, surveyors and inspectors from The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS) know and rely upon these regulations and guidelines to help steer the survey process. Surveyors are also ensuring facilities' policies and procedures reflect the latest evidence-based standards and guidelines, and that they are being consistently

followed throughout the health care organization, explained Rose Seavey, MBA, BS, RN, CNOR, CRCST, CSPDT, retired president and CEO of Seavey Healthcare Consulting. Seavey provided an educational session on point-of-use care during the 2019 IAHCSMM Annual Conference in Anaheim, California. Seavey pointed out that instrument care and handling is a joint responsibility between user departments and the SPD. Because biofilm, a mass of bioburden, can begin forming on instruments within minutes, she stressed the importance of engaging in proper point-of-use practices throughout and immediately following each patient procedure. This treatment involves wiping off gross blood and bioburden, keeping instruments covered with a water-moistened towel or wetted with an approved enzymatic product, and then ensuring the instruments are transported to the decontamination area in a safe manner and as quickly as possible post-procedure, in accordance with current regulations, standards and guidelines, and facility policies. AAMI, AORN and AST recommendations state that instruments that can be disassembled and opened should be done so at the point of use. The standards also state that sharps should be separated by personnel who understand the risk for injury – and such devices should be placed in a puncture-resistant container for safe transport. Seavey said TJC’s new scoring guidelines ensure surveyors will be looking for separation of sharps during inspections. It’s important to note that, per Occupational

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Safety and Health Administration (OSHA) regulations, contaminated items should never be transported in the same water in which they soaked, unless they are in a spill- and splashproof container. Single-use devices and other disposable waste should be removed and disposed of in the OR. Endoscopes also require diligent point-of-use treatment that includes suctioning and wiping down surfaces to aid the removal and break down of bioburden. Seavey clearly pointed out that point-of-use care and treatment does not translate to point-of-use cleaning, and reminded that devices shouldn’t be cleaned outside dedicated decontamination areas. Like other instruments, endoscopes should also be transported to the decontamination area and processed as soon as possible following their use. Some manufacturers’ instructions for use (IFU) clearly state that if reprocessing doesn’t begin with 60 minutes of use, extensive reprocessing will be required. All contaminated devices, regardless of type, should be covered for transport to the decontamination area and marked as “biohazardous.” This is true even if the surgical suite or procedure area is located near the decontamination area in the SPD. Risk assessments play another essential role in point-of-use care success and should be performed regularly to help determine process missteps and areas in need of immediate improvement. “We need to know what we know and close any gaps for the sake of our patients,” said Seavey. Julie Williamson is the IAHCSMM Communications Director/Editor.

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JANUARY 2020 | OR TODAY |

INDUSTRY INSIGHTS

WEBINAR SERIES

news & notes webinars

UVC Disinfection Presentation Delivers ‘Excellent Overview’ Staff report he OR Today webinar “How St. Francis Hospital Uses UV Disinfection to Provide a Cleaner Health Care Environment” was eligible for one (1) continuing education (CE) hour by the State of California Board of Registered Nursing.

Presenters Eric Grantham, unit director at Crothall/St. Francis Hospital, and Alice Brewer, clinical director of Tru-D SmartUVC, discussed the benefits of UVC disinfection and how it has been implemented and accepted at St. Francis Hospital. About 100 individuals tuned in for the Halloween afternoon webinar. In a post-webinar survey, attendees had good things to say about the presentation. “The presentation was spot on. The presenters knew their topic of interest and provided peer-reviewed studies to support the benefits of UV disinfection. The number one benefit of UV disinfection is patient protection from infection; while additional benefits follow like dominos – cost containment, improved patient satisfaction scores, physician engagement/approval scores and cost containment. Environmental services will see improvements in allocation of both human resources (time spent wiping down OR suites versus UV) and monies directed toward cleaning products. Use of UV disinfection is a win-win,” shared R. Scott, clinical educator. “Excellent overview of the processes implemented, and processes under advisement,” said J. Fine, infection preventionist. “I found it informative, and definitely something to explore further and get clarification about frequency of use at our facility,” said J. Theopolos, RN. “Great webinar! Thank you again for bringing innovations which are extremely effective in killing bacteria and viruses without exposing harsh chemicals into the environment,” said A. Henke, OR RN team lead. “Very informative! I’m always looking for better ways to clean patient care devices I work on and find it excit-

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“ OR Today provides a great service to all OR RNs through their interesting, informative and evidenced-based webinars.” –C . Wilson, Interim Perioperative Services Leader ing that now a whole room plus the devices in it can be disinfected at the same time! Really appreciate the explanation of how one device was shared in a large facility, and extremely impressed with the notable reductions in patient infections. I’m hoping this technology grows quickly so it becomes less costly and more accessible to the health care systems and public,” said J. McLaughlin, BMET II. “OR Today provides a great service to all OR RNs through their interesting, informative and evidenced-based webinars,” said C. Wilson, interim perioperative services leader. “Even though I am a current client of Tru-D Smart UVC, I wanted to hear how other hospitals have implemented their program, the barriers they faced and the successes they have seen. This webinar delivered exactly that and helped me with new ideas on how to use Tru-D Smart UVC in our facility in ways we had not yet implemented. I am blown away at the success other hospitals have seen and hope to add to our success soon,” said E. O’Farrell, infection prevention nurse.

Quality Impacts the Bottom Line The OR Today webinar “How the Details in Quality Impact Your Bottom Line” presented by Charlene Frizzera, a member of the RepScrubs board of advisors, delivered helpful insights. In the 60-minute webinar, Frizzera informed participants on topics ranging from hospital quality and care to government penalties and the effect they have on the bottom line.

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INDUSTRY INSIGHTS

newswebinars & notes

“ I am so thankful to have OR Today presentations available with very relevant and current topics! It is most helpful in keeping me up-to-date.” – E. Anderson, RN The webinar, which was sponsored by RepScrubs, provided free educational content to more than 100 attendees. The attendees gave the presentation high marks in a post-webinar survey. “The webinar was very interesting. The information she shared from her CMS background was enlightening,” said S. Sirois, BMET III. “Presented a few topics I hadn’t considered. Any opportunity to learn and keep patients and staff safe is well worth the time,” shared C. VanOrden, nurse manager. “I am so thankful to have OR Today presentations available with very relevant and current topics! It is most helpful in keeping me up to date,” said E. Anderson, RN. “Great data to support infection related issues such as HAIs. I will be sharing this information with my team. This is so important. It not only costs us money, but the patients as well. Just think what they are saying on their surveys … ‘I went to the hospital and came back with an infection.’ This is not the feedback we are looking for, especially in this day and age when we need our patients to speak highly of the care they received,” Director of Surgical Services T. Fuchs said. “The webinar was outstanding offering key insights into hospital-acquired infections. The speaker’s credentials were impressive and her knowledge base was extensive. Thank you for providing the high-quality educational experience,” said J. Greary, clinical consultant. “In my role as a growing infection preventionist, which

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is also a quality improvement role, I found the webinar to be very informative and helpful,” said D. Robbins, infection preventionist. “OR Today’s webinar series has timely topics with helpful information and also provide contact hours,” said C. Wilson, interim perioperative leader. “It was a great presentation. Helped bridge the knowledge gap of certain aspects of CMS requirements related to reimbursements, and the overall picture,” said G. Zimmerman, quality/regulatory services coordinator. “This was a very informative webinar and is a topic we should all continue to follow closely as we strive to reach zero healthcare-acquired infections,” said D. Drapiza, quality nurse consultant IP. “Excellent presentation! Speaker was very knowledgeable and brought up really interesting/relevant points which one might not have previously considered could present a problem with hospital-acquired infections. Very good presentation,” said S. Ellis, infection preventionist. 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.

Thank you to our sponsors:

JANUARY 2020 | OR TODAY |

INDUSTRY INSIGHTS

From left to right: Steve Morrisey, Laura Morrisey, OR Today President John Krieg, Joni Krieg, Laura Wells and Jed Wells from proud sponsor Bedroc are all smiles at the Healing Hands Helping Heroes Casino Night.

AORN

AORN of Middle Tennessee Fundraiser a Hit Staff report he Association of periOperative Nurses (AORN) of Middle Tennessee and REBOOT Recovery hosted the fifth annual Healing Hands Helping Heroes Casino Night on Thursday, November 7, at City Winery in Nashville, Tennessee to benefit the AORN of Middle Tennessee and REBOOT Combat Recovery.

The event raised an estimated $30,000 for the two nonprofit organizations to help further their missions and help accomplish the following: • P rovide AORN delegates with scholarships to attend the national AORN Symposium and Expo • P rovide quarterly scholarships to select chapter members to complete the Certified Nurse Operating Room (CNOR) exam or attend a continued education offering

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•R einstate the AORN Chapter Nurse of the Year Award • P rovide full REBOOT Combat Recovery scholarships to hurting military families in Middle Tennessee to our combat trauma healing course. These scholarships included meals, child care, curriculum and even one-on-one mentorship “Over the last several years, we have observed the hard work and dedication that the perioperative nurses in Middle Tennessee have provided to the patients in our community. AORN is a nonprofit membership association that was established in 1954 to promote safety and optimal outcomes by providing practice support and professional development opportunities to perioperative nurses. Since the founding, the association has expanded to include more than 275 U.S. chapters,” according to a press release. OR Today magazine was a proud sponsor of the event. Publisher

John Krieg said it was a wonderful event and he looks forward to being a part of future events. “OR Today was honored to be a part of such a great benefit. Our team is thankful for the opportunity to work with such great leaders at the AORN Nashville chapter and look forward to supporting the event next year,” Krieg said. REBOOT Recovery was founded in 2011 by a licensed occupational therapist specializing in traumatic brain injury and Post-Traumatic Stress Disorder (PTSD). REBOOT exists to address the overlooked spiritual aspects of combat trauma. The program focuses on issues of identity, false guilt, forgiveness and building an environment of healing. This organization has provided the Middle Tennessee chapter with many learning opportunities. Service members and their families will be assisted by receiving therapy with money generated from this event.

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INDUSTRY INSIGHTS AORN

8 1. Amanda Edmonson, Paul Gulley, Marilyn Burns Gulley and Anna Caeg enjoyed the Helping Hands Helping Heroes Casino Night. 2. Jeff Bell, Helen Sweeney and Keith Sweeney enjoyed raising money for a good cause. 3. Among those supporting the event were Chanel Miller, Chad Freedman, Melissa Duffy and Dr. Toni Khim. WWW.ORTODAY.COM

9 4. Healing Hands Helping Heroes Casino Night was sponsored by several companies including Karl Storz, STERIS, MTF Biologics, BOSS Instruments Ltd. and OR Today. 5. John Ryall, Lindsay Jackson and Amy Ryall smile for the camera. 6. Among those attending the fundraiser were Mike Peek, Marilyn Burns Gulley, Karen Morrow and Debbie Weston.

7. Emily Leaman, Megan Iwicki, Landon Reef, Jacob Stringfellow and Cary Leaman were happy to help make the fundraiser a success. 8. Jordan Caden, Kim Spence and Dr. Elizabeth Hevert were among those to support the Helping Hands Helping Heroes Casino Night fundraiser. 9. The Hero Light was sponsored by OR Today and Bedroc. JANUARY 2020 | OR TODAY |

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IN THE OR

market analysis

Headline Headline Deck

Endoscopy Market Reaches New Highs Staff report he global endoscopy market continues to grow along with minimally invasive surgeries and life expectancy rates.

“Endoscopy is now seeing a new wave of innovation, driven by the start-up boom, advances in technology such as AI and the need for incumbents to think beyond product enhancements for competitive differentiation,” according to Frost & Sullivan, a growth strategy consulting and research firm. A recent Frost & Sullivan analysis of the industry identifies and profiles the top 30 innovative products and their manufacturers, including new endoscopy products, AI-enabled image analysis solutions, robotic solutions, advanced visualization solutions and even therapy products for endoscopy. ”The global market for endoscopy devices is expected to grow from $43.40 billion in 2018 to $45.95 billion in 2019, representing a yearon-year growth rate of just 6.6%,” said Siddharth Shah, transformational health program manager, Frost & Sullivan. “How can top-ranked manufacturers boost growth further and capture higher market shares? The answer lies in competitive differentiation through innovation, driven predominantly by start-ups that attempt to transform endoscopy with the power of novel technologies.” Frost & Sullivan is not alone in predicting growth for the global endos-

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copy market in coming years. The global endoscopy devices market size is expected to reach $58.1 billion by 2025, according to a report by Grand View Research Inc., exhibiting a compound annual growth rate (CAGR) of 7.4% during the forecast period. A growing preference for minimally invasive endoscopic procedures, increasing geriatric population and an increase in the prevalence of target gynecological, urological and gastrointestinal diseases are key factors contributing to market growth, according to a press release. Technological advancements in endoscopes and visualization systems are also positively impacting the market, the release adds. MarketsandMarkets also predicts growth. “The global endoscopy equipment market is projected to reach $35.2 billion by 2024 from an estimated $25.6 billion in 2019 at a CAGR of 6.6% during the forecast period. The growth of this market is driven majorly by factors such as growing demand for endoscopy, growing investments, funds, and grants, rising number of hospitals and increasing hospital investments in endoscopy facilities, and technological advancements,” MarketsandMarkets reports. A report from Mordor Intelligence forecasts that the endoscopy devices market, which was valued at $25.2 billion in 2018, is expected to register

a CAGR of about 6.45% from 2019 to 2024. “The United States dominates the market and is expected to continue to do the same during the forecast period,” according to a Mordor Intelligence report. “Currently, the United States dominates the market for endoscopy devices, and it is expected to continue its strong hold for a few more years. An increasing number of treatments, along with a rising population that exhibits a higher prevalence of GI disorders, are driving the growth of the market. Mild GERD is estimated to affect 60% of the population in the United States, nearly half of which experience it on a weekly basis. Colon cancer is projected to be the third leading cause of cancer deaths in the United States, with approximately 150,000 diagnosed, annually. The number of annual gastro-intestinal procedures is also likely to grow, due to the growing prevalence of digestive disorders affecting all divisions of the population, and the expanding therapeutic capabilities of endoscopy devices.” “Furthermore, the increasing preference for less invasive surgeries and treatment possibilities continues to fuel technological advancements in the U.S. endoscopic devices market. This is allowing surgeons to treat more conditions, without resorting to open surgery,” the report adds.

JANUARY 2020 | OR TODAY |

IN THE OR

product focus

Fujifilm

Endoscopic MIS Portfolio Fujifilm partners with hospitals and ASCs providing a full line of core and interventional GI and minimally invasive surgical systems, accessories and systems integration services designed to meet the needs of endoscopists and surgeons across the clinical spectrum. With a “patient-first” philosophy in mind, it develops innovations focused on practical applications that can be utilized in everyday patient care, empowering physician performance and confidence in conducting routine and complex cases. Fujifilm partners with customers to help drive enhanced patient outcomes and health care efficiencies as they seek to enhance their growing business. •

CapsoVision Inc.

CapsoCam Plus Capsule Endoscopy The device is the size of a large vitamin capsule and holds four cameras and LED lights that capture images as the pill progresses through the GI tract. Similar devices on the market have a single forward-facing camera that sometimes misses pathology. The CapsoCam Plus cameras, which look sideways, get a very up-close and detailed view of the interior of the intestines. And, unlike other devices, this one is wireless and can be used on patients with pacemakers. A convenient CapsoCloud service allows the physician to review the video and create report from anywhere. •

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IN THE OR

product focus

Healthmark EndoCheck

Test the cleanliness of the biopsy channel of the flexible endoscope. The EndoCheck is a miniature chemistry kit that is simple to use and interpret. Simply swab the biopsy channel of the scope with the included soft-tipped long probe, clip off the swab into the vial. Mix the activating agent, shake vigorously, wait and then check for a color change. Depending on the type of test used, a color change indicates that blood residue or protein residue remains in the channel, and should be reprocessed. EndoCheck complies with ASTM Guide D7225. â&#x20AC;˘

Integrated Endoscopy NUVIS

The NUVIS single-use, sterile packaged, high definition, battery operated arthroscope from Integrated Endoscopy incorporates 21st century, simplified optical designs and components in high definition, has its own embedded cool LED, eliminating the need for a separate light source and cord, and comes packaged sterile, adaptable to any camera system. â&#x20AC;˘

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JANUARY 2020 | OR TODAY |

IN THE OR

product focus

Tricor Systems Inc. Dri-Scope Aid

The Dri-Scope Aid family of products assist in drying the internal channels of endoscopes. This is a crucial step in the infection control process. The Dri-Scope Aid automates the process by delivery of HEPA filtered air through each individual endoscope channel. The Jet~Stream can dry up to two scopes at once. It can sit on a countertop, mount to a wall or hang on an IV pole. The Dri-Scope Aid Cabinet can convert an existing scope cabinet into a complete drying system. It can also be purchased pre-mounted in a new cabinet for up to 16 scopes. •

Olympus

Spiration Valve System (SVS) The FDA-approved Spiration Valve System (SVS) is an innovative endobronchial technology that offers patients with severe emphysema a customized, minimally invasive treatment option for lung volume reduction with a favorable risk-benefit profile. In clinical trials, patients treated with the SVS experienced improved breathing, lung function and quality of life1.

1 Criner, GJ, et al. 2018. The EMPROVE Trial – a Randomized, Controlled Multicenter Clinical Study to Evaluate the Safety and Effectiveness of the Spiration Valve System for Single Lobe Treatment of Severe Emphysema. American Thoracic Society Conference. Abstract A7753.

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•

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IN THE OR

continuing education

Bariatric Surgery Update BY SUSANNE J. PAVLOVICH-DANIS, MSN, RN, ARNP-C, CDE, CRRN AND MICHAEL G. DANIS, BSN, RN, CCRN

ennifer, 5 feet, 4 inches tall, weighs 346 pounds. She has tried dieting for more than 20 years, each time with limited success, eventually regaining all her weight and then some. Previous attempts at exercise have been embarrassing. “Everybody just stares at me, and one gym even canceled my membership for fear that I would hurt myself and take legal action against them,” she recounts.

“I literally ate myself out of my job,” former police officer Richard reports. First, he was forced out of motorcycle duty and placed on desk assignment. Then, his supervisor fired him six months ago when his weight reached 400 pounds, and he could no longer get to work. Inactivity combined with depression contributed to Richard’s current weight of 462 pounds, supported by a 6-foot-1-inch frame. Melissa has struggled with her weight for 10 years, trying pills, diets, and even liposuction. Nothing seems to keep the weight off for long. Although she needs to lose only about 85 pounds, serious health conditions are affecting her quality of life, putting her at risk for developing hypertension, type 2 diabetes, and obstructive sleep apnea. Each of these patients satisfies es-

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tablished criteria as so severely obese or affected by moderate obesity that consideration of a surgical weight-loss intervention is appropriate. These life-altering interventions offer a viable option for many who have failed at more traditional weight loss methods.

A Serious Problem Nearly 70% of adults in the United States are overweight. Of those, more than one-third are obese. Shockingly, the inability to maintain a healthy weight is rapidly becoming an epidemic of youth. Data from the CDC’s National Center for Health Statistics indicate that 20.6% of adolescents ages 12 to 19 are obese, 17.4% of children ages 6 to 11 are obese, and 9.4% of children ages 2 to 5 are obese.1 The National Institutes of Health (NIH) uses body mass index (BMI) to categorize overweight and obesity in three grades. Grade 1 obesity is moderately overweight people with a BMI of 30 kg/m2 to 39.9 kg/m2. A BMI between 35 kg/m2 and 39.9 kg/m2 constitutes grade 2 obesity, and people with a BMI greater than 40 kg/m2 are grade 3, massively or morbidly obese.2 In 2014, Americans spent an average of $1,901 per obese individual to directly treat obesity and obesity-related diseases/

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 provide nurses, occupational therapists, and physical therapists with an overview of the care of patients who have undergone bariatric surgery. After studying the information presented here, you will be able to: •

Differentiate between surgical options available for severely obese individuals.

•

Identify psychosocial and quality-of-life issues affecting patients before and after bariatric surgery.

•

List metabolic and physiological considerations nurses must be aware of when caring for patients after bariatric surgery. WWW.ORTODAY.COM

IN THE OR

continuing education conditions such as knee replacements from wear, medications for type 2 diabetes, and other complications seen less frequently in nonobese patients. Obesity costs America $149.4 billion annually in health-related care.3 Thirty percent of annual dollars spent for obesity care is funded by federal programs such as Medicare. Twenty-seven percent of obesity care is funded by private health plans, and 11% is paid for by Medicaid. 4 The NIH supports surgical weightloss procedures for clinically, severely obese people with a BMI greater than 40 kg/m2 and those with a BMI greater than 35 kg/m2 who have medical conditions (e.g., cardiovascular problems, obstructive sleep apnea, cardiomyopathy, hyperlipidemia, degenerative joint disease, and diabetes) when other medical interventions have failed to prevent compounding chronic illnesses over a person’s life time.5 The NIH has recognized weight-loss surgery (WLS), also known as bariatric surgery, as a surgical specialty since 1992; both the American College of Surgeons and the American Medical Association consider it a subspecialty. WLS is not considered experimental or cosmetic.5 When candidates for WLS are identified, the screening procedure must be intense and realistic. Evidence-based clinical guidelines have been developed for both adults and adolescents to determine if a person qualifies for bariatric surgery. Morbidly obese patients can expect to be thinner after the procedure. However, they need to know that surgery is only a tool and the type of surgery will determine the amount of weight lost.6 While a candidate may lose half or even more of their excess weight within two years because of the surgery, lifestyle modifications must be made to prevent patients from regaining weight over time. Some programs incorporate cognitive behavioral therapy in the plan of care.7

Surgical Options Today, surgeons perform three types of WLS procedures — restrictive, malabsorptive, or a combination of both. ReWWW.ORTODAY.COM

strictive procedures involve the stomach only, reducing its volume with adjustable gastric banding (such as a LAP-BAND) or vertical-banded gastroplasty (VBG), so-called “stomach stapling.” The latter type of procedure more commonly involves complete resection of a portion of the stomach and is referred to as a gastric sleeve. The procedure helps patients lose weight by reducing their food intake. On the other hand, malabsorptive procedures facilitate weight loss through a reduction in calorie absorption. Gastric-banding procedures involve wrapping a device around the stomach to create upper and lower pouches. A small upper pouch restricts food intake by limiting the amount of food that can be ingested at a sitting. Early banding devices, placed by open surgical technique, were not adjustable. Now, surgeons laparoscopically insert devices that can be adjusted by changing the volume of the subcutaneous reservoir to control the degree of gastric constriction.8 With restrictive procedures, such as gastric banding or VBG, weight loss rates slow and the failure rate is higher compared to malabsorptive procedures; however, there are fewer postoperative major complications reported.9 The typical gastric volume after VBG is initially 2 ounces and may increase over time to about 6 ounces. At first, patients can consume only liquids and food particles no larger in diameter than a drinking straw. Unpleasant adverse effects, which usually result from not chewing well, overeating, or eating too quickly, may include vomiting and choking. Consequently, patients may alter their food choices to include high-calorie liquids, which may impede weight loss. Overeating also may result in band failure, requiring subsequent surgical intervention.11 The human body contains about 20 feet (7 meters) of small intestine. The earliest malabsorptive weight-loss procedure, the jejunoileal bypass, left about 12 inches of small intestine for digestion. This procedure, which resulted in many late complications, has not been per-

formed for more than 20 years. However, early surgical failures led to the recognition of obesity as a chronic disease that requires longer-lasting procedures rather than temporary measures that can be reversed after desired weight loss. Today, most weight-loss procedures combine gastric restriction and malabsorption measures, accounting for the volume of food consumed as well as how much intestinal mucosa is available for digestion and caloric absorption. The most common WLS procedure is the Roux-en-Y gastric bypass (RNY). One variation includes closing off the unused stomach portion with an incision; another detaches the stomach completely so that it remains free-floating. The newly created stomach pouch can hold about 30 mL. The first part of the small intestine then is surgically divided, the lower end is connected to the stomach pouch, and the top portion is connected farther down on the small intestine so that digestive enzymes from the bypassed stomach and small intestine are available to mix with the food as it passes through.12 Surgeons perform the RNY by both traditional open and laparoscopic techniques; a newer laparoscopic technique produces shorter recovery times and fewer postoperative complications.9 When performed by surgeons adept at laparoscopy, operative time and blood loss are less, critical care and entire hospitalization times are significantly shorter, and weight loss is not significantly different from traditional open techniques.10 The most drastic WLS performed today is the biliopancreatic diversion (BPD). This procedure removes a portion of the stomach and reroutes food into a short segment of the ileum, known as the “common channel,” reducing the mixing of pancreatic secretions and bile with food. Malabsorptive procedures may cause adverse effects different from those incurred with restrictive surgery. Patients may experience chronic diarrhea and “dumping syndrome,” a combination of symptoms after eating sweets that includes nausea, weakness, faintness, diaJANUARY 2020 | OR TODAY |

IN THE OR

continuing education phoresis, and diarrhea immediately after eating. Fruits, often necessary sources of nutrients, can be particularly problematic for these patients because of their high sugar content.13 A variation of the BPD, the duodenal switch (DS), preserves the pyloric valve and some of the proximal duodenum. The small segment of the retained duodenum protects against ulcer formation and perforation. With BPD-DS, most of the acid-producing fundus of the stomach is not simply stapled off and left behind but removed. BPD-DS has the lowest incidence of dumping syndrome and produces the most weight loss of all procedures.12 Some surgeons have begun performing the procedure laparoscopically, with a subsequent reduction in short-term postoperative complications.

What Can Go Wrong? After purely restrictive procedures that reduce gastric volume, patients quickly know their intake limit at one sitting. If they overeat, they feel pain or vomit. They need to chew foods thoroughly to avoid plugging up their stoma or vomiting. Nutritional deficits related to the reduction in food intake can occur if oral supplements are not taken. Anemia is less common with purely restrictive procedures, but it may occur if patients make poor nutritional choices and do not take recommended supplements. This is particularly true among women who are still menstruating.5 Complications of WLS are associated with the general surgical risk and the type of procedure. For example, complications after gastric restrictive procedures include increased incidence of gastroesophageal reflux disease and heartburn after nonadjustable gastric banding; mucosal swelling at site and gastric perforation shortly after surgery; and esophagitis, gastritis, a dilated, small upper pouch, or the stomachâ&#x20AC;&#x2122;s slipping above the band. The most common complications after malabsorptive procedures are gastric or duodenal leaks, although distal

34 | OR TODAY | JANUARY 2020

anastomosis site leaks leading to abscess, fistula formation, peritonitis, sepsis, adult respiratory distress syndrome, pulmonary embolism, myocardial infarction, and even death may occur; however, the overall mortality rate following WLS is less than 1%.10 Strictures also may develop, further increasing the risk for vomiting. Often, endoscopic dilation or stent insertions are successful in correcting this complication on an outpatient basis.10 Deep vein thrombosis (DVT) and pulmonary emboli also are possible; although, anticoagulant prophylaxis and early mobilization have lowered the risk for these complications.14 Long-term complications after malabsorptive or combination procedures include diarrhea, flatulence, or lactose intolerance. The development of Crohnâ&#x20AC;&#x2122;s disease also has been on the rise after malabsorptive or combination procedures.15 Patients may develop elevated liver enzymes or uric acid levels. Gallstones and calcium oxalate renal stones may occur. Patients also are at risk for neuropathy related to vitamin B-12 deficiency, night blindness from vitamin A deficiency, and elevated alkaline phosphatase levels, which occur when calcium and vitamin D intake are low. Because iron and calcium are primarily absorbed in the duodenum and jejunum (segments typically bypassed in most procedures), these patients are at risk for anemia and osteoporosis. Osteoporosis risk increases because malabsorptive bariatric procedures augment the patientâ&#x20AC;&#x2122;s risk of developing calcium and vitamin D deficiencies, leading to several changes in bone metabolism.16 Increased rates of vitamin D deficiency, secondary hyperparathyroidism, hypocalcemia, and bone turnover and loss all have been reported with both malabsorptive and restrictive procedures. Typically, the degree of bone changes depends on the amount of weight loss achieved by the procedure. The more drastic the procedure, the more significant increases in bone turnover and decreases in bone density. Post-operative bone density

can decline by as much as 14% in the proximal femoral regions, including the femoral neck and total hip.17 An increasing number of patients also have developed nephrolithiasis postoperatively, even if they had no history of stones before surgery. The stones, when analyzed in the lab, are most likely related to calcium and not uric acid abnormalities (90% vs. 10%). Inadequate hydration leading to urine concentration also contributes to stone formation, thus another reason to encourage fluids after malabsorptive procedures have been performed.18 Some of the complications affecting the nervous system often are disabling and irreversible. The neurological complications after WLS include Wernicke encephalopathy, optic neuropathy, myelopathy, polyradiculoneuropathy, and polyneuropathy. Myelopathy is the most frequently reported and disabling problem, with symptoms beginning about a decade after WLS. Typically, encephalopathy and polyradiculoneuropathy are acute and early complications. Myelopathy often can be traced to vitamin B-12 and copper deficiencies, but the other neurological complications have not been clearly associated with other nutritional deficiencies.19 When complications arise, revisions may be required. Bypassed segments of bowel are not permanently removed, but left in place; if weight reduction, protein loss, or diarrhea is excessive, the bowel can be lengthened. When weight loss is poor, the common channel can be shortened. To achieve durable weight loss, patients must adhere to dietary recommendations, suggestions to increase physical activity, close nutritional monitoring during rapid weight loss, and lifelong medical surveillance.20

Quality of Life and Other Benefits Sixty-seven percent of people with diabetes are overweight, of which 46% are obese. Successful WLS can help control blood glucose levels in these patients to the point that oral medications may WWW.ORTODAY.COM

IN THE OR

continuing education no longer be necessary.21 Also, WLS can lower blood pressure and reduce triglycerides and total cholesterol. Bad cholesterol, or low-density lipoprotein (LDL), diminishes, while good cholesterol, or high-density lipoprotein (HDL), remains the same, improving the LDL/HDL ratio. Other important coexistent conditions, such as asthma and obstructive sleep apnea, may disappear or improve after WLS.22 Obesity results in adipose cells becoming overloaded and unable to adequately serve as storage sites. Fat is deposited within ectopic sites, such as the muscles, liver, and pancreas, leading to metabolic deranagement.24 Fat is an abundant storehouse for hormones and proteins that regulate metabolic processes and affect the risk for developing many disorders, including diabetes, hypertension, diabetic kidney disease, and atherosclerosis. Bariatric surgery reduces the negative effects of the metabolic syndrome including reducing hyperglycemia, hyperlipidemia and hypertension, and providing long-term reduction of cardiovascular morbidity and mortality.25 Changes found in these adipocytederived hormone levels, including leptin, adiponectin, and visfatin, may provide an explanation for the observed improvements in numerous metabolic abnormalities associated with obesity after malabsorptive procedures have been performed.26 Research into the endocrine and metabolic effects after malabsorptive bariatric procedures may lead to drug therapies that can mimic results of WLS, without surgery.26 Malabsorptive bariatric procedures result almost universally in re-establishment of more normal patterns of insulin release in response to food intake, improved insulin sensitivity, and improvement of metabolic syndrome.24 Additional benefits of WLS also have been discovered, including improvement of nonalcoholic fatty liver disease, hypertension, and dyslipidemia.24,27,28 Positive cardiac findings also have been observed after bariatric surgery. WWW.ORTODAY.COM

One study revealed that patients undergoing bariatric surgery show a significant decrease in the amount of epicardial adipose tissue and left ventricular mass one year after the procedure. This reduction is accompanied by a substantial improvement in triglyceride levels and metabolic control.29 Activity tolerance also improves after WLS as musculoskeletal pain diminishes, especially in the knee and ankle joints. This often facilitates increased physical activity, which complements weight loss.30 The major measure of WLS success often revolves around improvement of medical conditions. However, changes in physical, functional, and mental health may uniquely influence how patients perceive their quality of life. One instrument, the Bariatric Analysis and Reporting Outcome System, allows for international comparisons of excess weight loss, medical condition improvement, and quality of life.31 Research has shown that WLS procedures enhance patientsâ&#x20AC;&#x2122; quality of life and long-term outcomes, despite possible revisional procedures, adverse GI effects, and necessary lifestyle modifications.31 Typically, patient satisfaction after WLS is very high, and many obese patients have reported better social acceptance, support from others, and easier social adjustment.30 Patients have found jobs more easily than when they were obese and report less absenteeism. Feelings of rejection and shame diminish postoperatively, and patients after WLS report improvement in their sexual functioning, self-esteem, and body image. Greater ease in performing activities of daily living also improves quality of life.30,32 For women, bariatric surgery can affect reproduction significantly, requiring both pre- and postoperative considerations. After WLS, the ability to become pregnant is enhanced, similar to the improvements seen after massive nonsurgical weight loss, because of the normalization of sex hormones.33 Bariatric surgery also has been shown to

enhance the likelihood of success with fertility treatments among women who still experience ovulatory abnormalities after surgery.33 A change also may occur in the response to oral contraceptive hormones, making surgical or barrier contraceptive choices more favorable in those wishing not to become pregnant. Counseling patients on options to delay pregnancy are especially important for women who desire to become pregnant post procedure, as a delay of one to two years is recommended.34 The obesity epidemic among adolescents also has contributed to a significant increase in WLS surgery, necessitating specialized programs to prepare them for post-WLS changes that will last the remainder of their lives. Growth and development considerations both physically and psychologically make bariatric surgery among adolescents safe and effective with careful patient selection (but not without complication risk).35

Body Contouring â&#x20AC;&#x201D; The Finishing Touch Massive weight loss may generate functional and aesthetic deformities. Weight loss after WLS often produces large amounts of sagging skin that has lost elasticity. Pannus formation increases with patient age. Associated physical problems may result, particularly with excess sagging tissue in the abdominal region, known as the panniculus. Many obese people have moderate to large panniculi that compound the physical, social and emotional problems of obesity. A large panniculus is not simply a cosmetic concern, but poses problems related to hygiene, chronic skin inflammation or infection, and back pain.36 The removal of the panniculus can be combined with the initial WLS procedure or after weight loss has occurred. Surgeons often perform procedures, such as abdominoplasty (tummy tuck) or a full-circumference removal of truncal skin (sleeve lipectomy), in which two 360-degree cuts are made around the upper and lower abdomen. The in-between JANUARY 2020 | OR TODAY |

IN THE OR

continuing education skin is removed and discarded, and the skin above and below is reconnected. Other needed surgery may include thigh lifts, arm tucks, and removal of neck skin. Nutritional deficits that follow malabsorptive procedures can complicate recovery.37 These procedures may be covered by insurance if the initial WLS was covered; patients need to check with their carriers to be sure. Additional procedures create physiological demands that require patients to be optimally nourished before, during, and after surgery for adequate healing and repair. Properly prepared and nourished patients following WLS perform quite well and pose no greater risk than obese patients who have not undergone WLS for body contouring.36 Besides improving patients’ physical disabilities related to excess skin, their overall appearance and sense of well-being are enhanced greatly.38

Psychological Issues Morbidly obese patients often experience discrimination, humiliation, and embarrassment due to weight problems. Others may believe they lack self-control or have a weak character. However, no specific personality type is associated with obesity. Although image disparity (a distorted self-image) and eating disorders (particularly binge eating) are common among the morbidly obese, the incidence of psychological disorders, such as depression, anxiety, or substance abuse are no greater than among those of healthy weight.39 Situational depression related only to obesity is common and depressed patients tend to lose more weight postoperatively. These patients also may have other psychiatric disorders that require monitoring not only before surgery, but after as well, to increase the chances for successful weight loss and maintenance. Research findings indicate that morbidly obese patients may experience more disordered eating behaviors postoperatively than those without psychological diagnoses. This is particularly true if their psychological disorders are not addressed postoperatively.40 Psychiatric evaluation and counsel-

36 | OR TODAY | JANUARY 2020

ing are important in WLS planning and follow-up. Patients need to know that they will receive both positive and negative responses from others related to their weight loss and the chosen method to achieve it. Serious psychological disorders, such as schizophrenia or substance abuse, contraindicate WLS because of the necessity for postoperative adherence and follow-up.39 Patients with the best outcomes have strong support systems, although those with less support also can perform very well. To enable the best post procedure outcome, there are many comorbidities that must be evaluated and managed. Patients can benefit from involving spouses and other family members in care planning before surgery. However, WLS may not help patients with marital problems. WLS does not improve marital satisfaction significantly; in fact, when these patients lose weight and improve their self-image and self-esteem, divorce is common.39 For others, WLS support groups are an option.

The Nurse’s Role A nurse’s role may start in the clinician’s office, where preoperative education addresses physical, psychosocial, and nutritional factors. Nurses must prepare patients for the positive health benefits as well as potential unpleasant physical effects of WLS. Some nurses may not get the opportunity to be involved in the preoperative phase and may care for patients only in the extended postoperative phase due to an increase in medical tourism. Patients may travel to foreign countries for their bariatric procedures because of reduced expenses abroad. When they return, complications must be managed by providers who were not initially involved in the patient’s care. This can result in increased physical and emotional distress for patients. Also, it can result in financial burden as the post procedure complications may not be covered by their healthcare plan.41 In the inpatient care setting, the nurse’s immediate postoperative role is both educational and supportive. Much

of the postoperative course is similar to that of other obese individuals who have undergone abdominal surgery, with a few exceptions.11 For example, regardless of surgical approach, patients who have undergone WLS must be encouraged to splint their abdomen, cough, and deep breathe to avoid atelectasis. Incision lines, laparoscopic insertion sites, and drainage devices need monitoring. If an abdominoplasty is performed at the same time, and the inpatient stay is brief, patients may leave the hospital with drains and require education about their proper care. Patients who still menstruate will be at a much greater risk for anemia, particularly if they take anticoagulants to prevent DVT. One way to reduce the risk of DVT for all WLS patients is to get them up and walking early in their postoperative period and direct them to wear antiembolic stockings or use compression devices. Surprisingly, patients are not usually hungry during the early postoperative phase, when they are often only permitted liquids. As recovery progresses, so does the diet. At first, patients can eat only a few bites of food. Chewing carefully is important to prevent choking or food blockage at narrowed surgical sites. Patients’ diets eventually advance to three small meals a day; they should avoid snacking between meals. Limitations will quickly become apparent, and overeating will cause vomiting. Nurses must prepare patients psychologically for follow-up surgical procedures if blockages occur. Advise patients to eat slowly and push away from their plate when they feel full, regardless of how much food is left. Patients should learn to make smart nutritional choices to achieve a full feeling. For example, liquids should have low or no caloric value, such as water or diet beverages. Patients should avoid alcohol, which offers no nutritional value. Fruits should be consumed as solids, not as juices, to permit a sense of fullness and nutritional balance. Patients who do not adhere to nutritional recommendations may experience hair loss from altered protein metabolism, require nutrient injections, or be at greater WWW.ORTODAY.COM

IN THE OR

continuing education risk for autoimmune disorders. Selecting complex carbohydrates and proteins is as important as restricting fats and sugars. Patients should first consume protein, such as meats, eggs, fish, dairy products, legumes, or nuts, which then can be followed by carbohydrates (if they are not yet full). If protein intake is inadequate, powdered supplements blended into smoothies may be used, particularly during the early recovery period when solids are less tolerated. Nurses can reinforce nutritional concepts and promote appropriate food choices that are stressed during in-depth education sessions with dietitians. One way for patients to evaluate their areas of concern is to keep a food diary. Flatulence, abdominal cramping, and diarrhea are common postoperative problems for which avoidance of highfat foods is required. Spray deodorizers can be used to immediately neutralize biological odors in the air. Consuming chlorophyll or activated charcoal tablets also is a helpful intervention; however, charcoal tablets can interfere with the absorption of many medications and must not be advised without careful medication review.Patients may need help evaluating financial resources, which may be needed for frequent, complete wardrobe changes, as well as medical office visits, diagnostic studies, and potential lost wages from time off work for recovery. Some balance may be achieved with the reduction in money spent for food offsetting WLS-related expenses. When resources are limited, WLS support groups and thrift shops may provide low-cost, short-term clothing. Nurses must stress that WLS encompasses a total lifestyle change and should not be viewed as an easy or quick weightloss intervention. Morbidly obese patients benefit from WLS procedures physically, psychologically, and socially. Their risk for complications from many diseases often is diminished, if not eliminated. However, benefits require lifelong dietary modifications and follow-up to prevent complications. WLS success depends on a motivated patient, selection of the appropriate

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procedure, a commitment to follow-up, and the coordinated collaborative effort of many healthcare professionals, including nurses in inpatient, outpatient, and community settings. For more information, please visit: www.asmbs.org.

Gastric Bypass with Lesser Curve Pouch & Roux-en-Y

How to Calculate BMI BMI charts are available, but if you do not have access to one, here is how to easily calculate a BMI: Multiply weight in pounds by 704.5; then divide that number by height in inches, twice. For example: For a patient who is 240 pounds and 5 feet, 7 inches: (a) 240 Ă&#x2014; 704.5 = 169,080 (b) 169,080/67 = 2523.58 (c) 2523.58/67 = 37.6 (round up to 38) Susanne J. Pavlovich-Danis, MSN, RN, APNP-C, CDE, CRRN is an adult nurse practitioner in private practice in Plantation, Florida.

Non-Adjustable Gastric Banding

Transected Roux-en-Y Gastric Bypass

Michael G. Danis, BSN, RN, CCRN, is a Trauma/Neuro ICU nurse at Memorial Regional Hospital in Hollywood, Florida.

Biliopancreatic Diversion

Vertical Banded Gastroplasty

Biliopancreatic Diversion with Duodenal Switch

JANUARY 2020 | OR TODAY |

IN THE OR

continuing education

References 1. Centers for Disease Control and Prevention. Obesity and Overweight. Available at: https://www.cdc.gov/nchs/ fastats/obesity-overweight.htm Updated May 3, 2017. Accessed April 3, 2019. 2. National Heart, Lung, and Blood Institute. Classification of overweight and obesity by BMI, waist circumference, and associated disease risks. Available at: https://www.nhlbi.nih.gov/health/ educational/lose_wt/BMI/bmi_dis.htm. Accessed April 19, 2019. 3. Kim DD, Basu A. Estimating the medical care costs of obesity in the United States: Systematic review, metaanalysis, and empirical analysis. Value Health 2016;19:602-613. doi: 10.1016/j. jval.2016.02.008. 4. Jacob JA. Obesity-related medical care costs Medicaid $8 billion a year. JAMA 2015;314:2607. doi:10.1001/ jama.2015.16829. 5. National Heart, Lung, and Blood Institute. Managing overweight and obesity in adults: Systematic evidence review from the Obesity Expert Panel. Available at: https://www.nhlbi.nih.gov/health-pro/ guidelines/in-develop/obesity-evidencereview. Published November 2013. Accessed April 19, 2019.

11. Kim SB, Kim SM. Can the long-term complications of adjustable gastric banding be overcome? Preliminary results of adding gastric plication in patients with impending gastric band failure. J Laparoendosc Adv Surg Tech A 2015;25:702706. doi: 10.1089/lap.2015.0199. 12. American Society for Metabolic and Bariatric Surgery. Bariatric surgery procedures: Overview. Adjustable gastric band: The procedure. Available at: https:// asmbs.org/patients/bariatric-surgeryprocedures#band. Accessed April 19, 2019. 13. Banerjee A, Ding Y, Mikami DJ, Needleman BJ. The role of dumping syndrome in weight loss after gastric bypass surgery. Surg Endosc 2013;27:1573-1578. 14. Bartlett MA, Mauck KF, Daniels PR. Prevention of venous thromboembolism in patients undergoing bariatric surgery. Vasc Health Risk Manage 2015;77:461-477. doi: 10.2147/VHRM.S73799.

24. Malin SK, Kashyap SR. Differences in weight loss and gut hormones: Rouen-Y gastric bypass and sleeve gastrectomy surgery. Curr Obes Rep 2015;4:279-286. doi: 10.1007/s13679-015-0151-1.

15. Braga Neto MB, Gregory M, Ramos GP, et al. De-novo inflammatory bowel disease after bariatric surgery: A large case series. J Crohns Colitis 2018;12:452-457. doi: 10.1093/ecco-jcc/jjx177.

25. Corcelles R, Daigle CR, Schauer PR. Metabolic effects of bariatric surgery. Eur J Endocrinol 2016;174:R19-28. doi: 10.1530/EJE-15-0533.

6. Mayo Clinic. Bariatric surgery. Available at: https://www.mayoclinic.org/testsprocedures/bariatric-surgery/about/pac20394258. Accessed April 19, 2019. 7. Paul L, van der Heiden C, Hoek HW. Cognitive behavioral therapy and predictors of weight loss in bariatric surgery patients. Curr Opin Psychiatry 2017;30:474-479. doi: 10.1097/ YCO.0000000000000359.

17. Scibora LM. Skeletal effects of bariatric surgery: Examining bone loss, potential mechanisms and clinical relevance. Diabetes Obes Metab 2014;16:1204-1213. doi: 10.1111/dom.12363.

8. Beitner MM, Ren-Fielding CJ, Fielding GA. Reducing complications with improving gastric band design. Surg Obes Relat Dis 2016;12:150-156. doi: 10.1016/j. soard.2015.08.520.

18. AC Valezi, PE Fuganti, JM Junior, Delfino VD. Urinary evaluation after RYGBP: A lithogenic profile with early postoperative increase in the incidence of urolithiasis. Obes Surg 2013;23:1575-1580. doi: 10.1007/s11695-013-0916-0.

9. Lin YH, Lee WJ, Ser KH, et al. 15-year follow-up of vertical banded gastroplasty: Comparison with other restrictive procedures. Surg Endosc 2016;30:489494. doi: 10.1007/s00464-015-4230-x.

19. Kumar N. Neurologic complications of bariatric surgery. Continuum (Minneap Minn) 2014;20:580-597. doi: 10.1212/01. CON.0000450967.76452.f2.

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22. van Huisstede A, Rudolphus A, Castro Cabezas M, et al. Effect of bariatric surgery on asthma control, lung function and bronchial and systemic inflammation in morbidly obese subjects with asthma. Thorax 2015;70:659-667. doi: 10.1136/thoraxjnl-2014-206712. 23. Del Genio G, Limongelli P, Del Genio F, et al. Sleeve gastrectomy improves obstructive sleep apnea syndrome (OSAS): 5 year longitudinal study. Surg Obes Relat Dis 2016;12:70-74. doi: 10.1016/j. soard.2015.02.020.

16. Ben-Porat T, Elazary R, Sherf-Dagan S, et al. Bone health following bariatric surgery: Implications for management strategies to attenuate bone loss. Adv Nutr 2018;9:114-127. doi: 10.1093/advances/nmx024.

10. Chang SH, Freeman NLB, Lee JA, et al. Early major complications after bariatric surgery in the USA, 2003â&#x20AC;&#x201C;2014: A systematic review and metaâ&#x20AC;?analysis. Obesity Reviews 2017;19:529-537. doi: 10.1111/obr.12647.

21. Khalaf KI, Taegtmeyer H. Clues from bariatric surgery: Reversing insulin resistance to heal the heart. Curr Diabetes Rep 2013;13:245-251. doi: 10.1007/s11892013-0364-1.

20. Kruger RS, Pricolo VE, et al. A bariatric surgery center of excellence: Operative trends and long-term outcomes. J Am Coll Surg 2014;218:1163-1174. doi: 10.1016/j.jamcollsurg.2014.01.056.

26. Behary P, Cegla J, Tan TM, Bloom SR. Obesity: Lifestyle management, bariatric surgery, drugs, and the therapeutic exploitation of gut hormones. Postgrad Med 2015;127:494-502. doi: 10.1080/00325481.2015.1048181. 27. Dixon JB, Lambert EA, Lambert GW. Neuroendocrine adaptations to bariatric surgery. Mol Cell Endocrinol 2015;418:143152. doi: 10.1016/j.mce.2015.05.033. 28. Popov VB, Lim JK. Treatment of nonalcoholic fatty liver disease: The role of medical, surgical, and endoscopic weight loss. J Clin Transl Hepatol 2015;3:230-238. doi: 10.14218/JCTH.2015.00019. 29. Luaces M, Paiva M, Gonzalez S, et al. Long-term changes in epicardial adipose tissue after bariatric surgery: A CMR study. J Am Coll Cardiol 2013;61:E1286. 30. Sarwer DB, Steffen KJ. Quality of life, body image and sexual functioning in bariatric surgery patients. Eur Eating Disord Rev 2015;23:504-508. doi: 10.1002/ erv.2412. 31. Wolf AM, Falcone AR, Kortner B, Kuhlmann HW. BAROS: An effective system to evaluate the results of patients after bariatric surgery. Obes Surg 2000;10:445-450.

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CE267-60

How to Earn Continuing Education Credit

32. O’Brien PE, MacDonald L, Anderson M, et al. Long-term outcomes after bariatric surgery: Fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg 2012;257:87-94. doi: 10.1097/ SLA.0b013e31827b6c02. 33. Milone M, De Placido G, Musella M, et al. Incidence of successful pregnancy after weight loss interventions in infertile women: A systematic review and meta-analysis of the literature. Obes Surg 2016;26:443-451. doi: 10.1007/s11695-015-1998-7. 34. Chor J, Chico P, Ayloo S, et al. Reproductive health counseling and practices: A cross-sectional survey of bariatric surgeons. Surg Obes Relat Dis 2015;11:187-192. doi: 10.1016/j.soard.2014.05.031. 35. Relles D, Zitsman JL. Bariatric surgery in adolescents. In: Freemark MS, ed. Pediatric Obesity 2017: 661-681. Washington DC: Springer. 36. Chung CW, Kling RE, Sivak WN, et al. Risk factors for pannus formation in the post-bariatric surgery population. Plast Reconstr Surg 2014;133:623e627e. doi: 10.1097/PRS.0000000000000101. 37. Herman CK, Hoschander AS, Wong A. Post-bariatric body contouring. Aesthet Surg J 2015;35:672687. doi: 10.1093/asj/sjv008. 38. McLeod B, Beban G, Sanderson J, et al. Bariatric surgery makes dramatic difference to health-related quality of life. N Z Med J 2012;125:46-52. 39. Marek RJ, Ben-Porath YS, Heinberg LJ. Understanding the role of psychopathology in bariatric surgery outcomes. Obes Rev 2016;17:126-141. doi: 10.1111/obr.12356. 40. Edwards-Hampton SA, Wedin S. Preoperative psychological assessment of patients seeking weight-loss surgery: Identifying challenges and solutions. Psychol Res Behav Manage 2015;8:263-272. doi: 10.2147/PRBM.S69132. 41. Kim DH, Sheppard CE, de Gara CJ, et al. Financial costs and patients’ perceptions of medical tourism in bariatric surgery. Can J Surg 2016;59:59-61.

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

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Accredited In support of improving patient care, OnCourse Learning (a Relias LLC company) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider #50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. Relias LLC is approved by the California Board of Registered Nursing, provider # CEP13791.

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ANTIMICRO

STEWA

“A

ntimicrobial stewardship

provides guidance for the safe and cost-effective use of antimicrobial agents.” – L i n d a K . C o n n e l ly

40 | OR TODAY | JANUARY 2020

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OBIAL

By Don Sadler

WARDSHIP P e r i o p e r at i v e P r o f e s s i o n a l s P l ay C r i t i c a l R o l e

ntimicrobial agents are critical to destroying or severely inhibiting the growth of pathogenic microorganisms. Since antibiotics are given preoperatively in hospital operating rooms and ambulatory surgery centers as part of SSI prevention, it’s critical for hospitals and ASCs to create an antimicrobial stewardship program (ASP).

W h at i s A n t i m i c r o b i a l S t e wa r d s h i p ? The Association for Professionals in Infection Control and Epidemiology (APIC) defines an ASP as follows: “Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multi-drug resistant organisms.” According to APIC, the term antimicrobial encompasses the treatment options for all forms of microbes. These include antibiotics to treat bacteria, antifungals to treat fungi and antivirals to treat viruses. “Antimicrobial stewardship provides guidance for the safe and cost-effective use of antimicrobial agents,” says Linda K. Connelly, PhD, MSH, ARNP, CNOR, COL (retired) USA Nurse Corps and a professor at the University of North Florida Brooks College of Health School of Nursing. “A primary goal of this stewardship is to minimize unintended consequences such as toxicity and resistance to the antimicrobial that will optimize clinical outcomes,” Connelly adds. “A coordinated ASP is imperative to promoting the proper use of antimicrobials,” says Vangie Dennis, MSN, RN, CNOR, CMLOS, executive director, WellStar AMC. “It should include improvement in patient outcomes, along with assists in sustaining a reduction in microbial resistance and the spread of infections that can be caused by multidrug-resistant organisms.” According to Terri Link, MPH, BSN, CNOR, CIC, CAIP, FAPIC, product manager, guideline implementation tools with the Association of periOperative Registered Nurses (AORN), antimicrobial

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JANUARY 2020 | OR TODAY |

stewardship in the OR and ASCs cal infections,” says Connelly. The Role of the Perioperative Team includes the appropriate timing In her role as faculty, ConConnelly stresses the importance and the right dosage and redosing nelly says she includes the topic of of the perioperative team working for extended procedures. antimicrobial stewardship in her together to make sure that the anti“Antimicrobials should be perioperative and medsurg courses. microbial stewardship program is in administered before the incision “I teach students that nurses are place and followed for each patient. is made or before the tourniquet integral to organizational change,” “Perioperative nurses need to be is inflated, and dosages should be she says. “Nurses need to take a included on the team that manages administered based on the paleadership role in the guidance of antimicrobials,” says Connelly. tient’s weight,” says Link. “Proper optimal use of therapies and stay “In fact, I believe that the peridocumentation will allow for audits current on evidence-based practices operative nurse can be the lynchpin of appropriate use of antibiotics, and guidelines.” for this process,” Connelly adds. including surveillance for SSIs.” AORN is an excellent source Another consideration is the use to stay current on evidence-based of antibiotics in the case of allerpractices in the perioperative setgies. “Appropriate screening and ting, Connelly adds. “But nurses consultation with a pharmashould go beyond AORN to cist may ensure that the other sources such as the CDC second line antibiotic is as well,” she says. PERIOPERATIVE NURSES WORK appropriate and effecConnelly believes that tive,” says Link. the perioperative nurse’s CLOSELY WITH SURGEONS AND Workflow should role can start with also be a considerenhancing infection HAVE THEIR EAR, WHICH IS ation. “Some antibiprevention and control. otics take longer to “This is especially true IMPORTANT SINCE SURGEONS infuse and decisions in an ambulatory setting about what antibiotsince these patients will ARE AT THE TOP OF THE LIST ic to use are based on be assessing themselves this,” says Link. “Havafter their short stay OF DOCTORS WHO ENGAGE IN ing an interdisciplinat the facility,” she says. ary team that develops “This makes nurse educaPRESCRIBING ANTIBIOTICS. standardized processes tion key.” for antibiotics is imporAccording to Dennis, an– L I N D A K . C O N N E L LY tant in any antimicrobial timicrobial stewardship needs stewardship program.” to be applied across the conLink emphasizes that an tinuum of care. “This is especially ASC’s governing body – which is true within an ASC setting, since interdisciplinary and includes either there are limitations with patient a pharmacist on staff or contracted relationships and it can be difficult “Perioperative nurses work closely pharmacist – should establish practo reconnect with patients after with surgeons and have their ear, tices that include the appropriate discharge,” she says. “Being proacwhich is important since surgeons antibiotics for the procedure being tive helps decrease infection rates are at the top of the list of doctors performed and the organisms most while improving patient care and who engage in prescribing antibiotics.” likely to be the cause of an SSI for outcomes.” “Not only do surgeons that procedure. oversee antibiotic prescriptions for Avoiding Antibiotic Overuse “This is often a broad-spectrum surgical prophylaxis on a daily basis, Beverly Kirchner, BSN, RN, CNOR, antibiotic that covers a wide range but they also usually manage surgiCASC, corporate compliance officer of organisms,” says Link.

“

”

“Being proactive helps decrease infection rates while improving patient care and outcomes.” – Vangie Dennis

42 | OR TODAY | JANUARY 2020

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with SurgeryDirect LLC, notes that studies have shown that overuse of antibiotics is resulting in multi-drug resistant organisms and antibioticresistant infections. She points to data compiled by the CDC revealing that at least 30 percent of antibiotic courses prescribed in the outpatient setting are unnecessary. Total inappropriate antibiotic courses may approach 50 percent of all outpatient antibiotic use, notes the CDC. “Our goal is to wipe out SSIs, not create a bigger problem by providing antibiotics that are not needed or are not appropriate for the patient,” says Kirchner. “At the very least, antimicrobial stewardship programs should address a commitment to decrease the use of antibiotics and encourage physicians to write fewer antibiotic prescriptions for patients after surgery.” Connelly concurs, noting that antibiotic resistance is a “global threat” and that the overuse of antibiotics contributes to the problem, along with patients not completing their prescriptions. “Perioperative nurses can educate patients about the importance of completing prescriptions and even follow up with them after they’ve been discharged,” she says. Kirchner encourages facility leaders and infection preventionists to work together to write policies and procedures addressing antibiotic usage and then follow them. “The leadership team needs to be educated in the appropriate use of antibiotics and ensure that all team members are educated as well,” she says.

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“Tracking and reporting of SSIs is a critical component of a stewardship program,” Kirchner adds. “The infection preventionist, working with the pharmacy consultant, needs to track antibiotic use and report not only this, but also if the use of the antibiotics was appropriate for the patient based on the diagnosis.” Kirchner suggests that facilities can reduce SSIs and the overuse of antibiotics by following best practices in a number of different areas, such as using safe injection practices, using clippers to remove hair before procedures in the perioperative area and practicing effective hand hygiene. “In addition, perioperative nurses should encourage patients to cleanse their skin prior to admission by educating them on the importance of this during the preadmission call,” she adds. “Nurses should also provide extensive post-operative instructions to the patient’s family regarding infection prevention practices, such as the importance of frequent hand washing.”

LINDA K. CONNELLY,

PhD, MSH, ARNP, CNOR, COL

TERRI LINK,

MPH, BSN, CNOR, CIC, CAIP, FAPIC

Perioperative Nurse’s Role is Critical Connelly believes that the role of perioperative nurses in antimicrobial stewardship cannot be overstated. “Perioperative nurses are very involved in antimicrobial therapy,” she says. “Therefore, I feel they should also be very involved in antimicrobial stewardship.”

JANUARY 2020 | OR TODAY |

Spotlight On:

Tamara

Kear By Matt Skoufalos

rom the age of five, Tamara Kear knew she was going to be a nurse when she grew up. She can’t think of a time she’d considered any other profession.

“When I got into high school, I created my course load to lead me toward that direction and never went back,” she said. Kear was raised around hospital talk because her grandmother, Mary, supervised the in-house bakeshop at Union Hospital in Terre Haute, Indiana. But during her own childhood doctor’s visits, “nurses were scary to me,” Kear said. It didn’t deter her from her chosen profession, but it made her realize that nurses didn’t have to be frightening – and when she became one, she carried the memories with her. In the middle of her nursing school education at GwyneddMercy University in Gwynned Valley, Pennsylvania, Kear’s father passed away. Suddenly, her mother, Marilyn, a Realtor, was looking at a career change, and she decided to enter nursing school as well. So while Tamara’s career was beginning in the med/surg unit at Doylestown

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Hospital in Doylestown, Pennsylvania, Marilyn was setting out on a path that took her from public school nursing to an eventual career at Children’s Hospital of Philadelphia (CHOP). It was at Doylestown Hospital that Kear made her entrance into nephrology, the specialty that would occupy the bulk of her professional career. Her earliest moments in that education came on a floor where patients were receiving dialysis treatment. “There was a very small patient underneath her covers in her bed, all balled up,” Kear said. “The nurse said, ‘Make sure this patient doesn’t get peritonitis.’ I spent the night reading through the policy and procedure manual, got a little bit of help from my supervisor … and my patient didn’t get peritonitis.” “[From that experience], I realized how much I enjoyed caring for the chronically ill population who had a lot of physiologic imbalances,” Kear said. “I knew from the beginning that this was probably going to be my career path.” Not long after, she got a job in the dialysis unit at Thomas Jefferson University Hospital in nearby Phila-

delphia, and six months in, began a master’s degree program to help patients with kidney failure. That led to an internship with a local organ procurement organization, and an advanced practice role as a clinical specialist at Jefferson. The majority of her career since has been spent in nephrology nursing. Kear attributes the reason she’s stuck for so long in the field to a single word: community. In the years she spent in patient care at Jefferson, many of her patients received continuing care. Some would be in three times a week for a decade or more, and others far more briefly. However long she spent with them, Kear enjoyed the sense that she was making a difference in their lives, whether improving the quality of care they received, or simply making them as comfortable as possible throughout a difficult experience. She also honed her voice as a patient advocate, a skill that’s aided her on her parallel career track as a 20-year undergraduate nursing educator. “I’ve had the opportunity to see my students go on, change roles, get degrees and move the profession of nursing forward,” Kear said. WWW.ORTODAY.COM

Away from work, Tamara Kear enjoys spending time with her husband, Brad, and their adult children, Kathryn and Colin.

“I continue to see the impact of the changes they’ve made.” One of the challenges she faces as an educator is preparing her students for practice. The activities of nursing students are restricted by a variety of regulations, some from the world of health care, and some from the world of academia. In preparing them for graduation, residency, and eventually, a full-time career, Kear stresses the importance of delivering “the best education we can provide” through a variety of settings. “It’s a very exciting time for us, but we struggle with building the pipeline and workforce issues,” Kear said. “Those who enter nephrology nursing, we’ve seen traditionally that they stay within the specialty.” In addition to her efforts in the classroom, Kear also has traveled internationally with her students to provide health care to places that may not have electricity or clean water. In collaboration with Good Samaritan Hospital in La Romana, WWW.ORTODAY.COM

“We do our best to understand their culture, and then we bring the education that they may not have. The students become flexible; they learn to improvise to provide care without the modern conveniences.” Dominican Republic, Kear’s students help deliver care into communities where Haitian immigrants live and work in the sugar cane fields. “They have physicians, they have translators, but they don’t have the strong nursing piece,” she said. “We do our best to understand their culture, and then we bring the education that they may not have. The students become flexible; they learn to improvise to provide care without the modern conveniences.” Kear said her students often develop an understanding of social determinants of health in countries where people form strong community bonds out of the necessity of survival. Americans who haven’t enjoyed those experiences at home return with a

sense of connection, “and they come back enriched by what they have in those countries, which has nothing to do with money,” she said. “When our students look at some of the challenges that we have in the United States, sometimes those challenges are no different,” Kear said. “Although the environment may look very different, a lot of those inequities still exist. That helps the students put it in context.” In her free time, Kear enjoys spending time with her husband Brad; both are active runners. Their daughter, Kathryn, is a dietetic intern at Brigham and Women’s Hospital in Boston, Masachusetts, and their son, Colin, is studying business at the University of Vermont. JANUARY 2020 | OR TODAY |

OUT OF THE OR fitness

3 Behaviors for a Healthy & Strong 2020 By Miguel J. Ortiz enry Ford once said, “Whether you think you can, or you think you can’t – you’re right.” When I first heard this quote I was pretty taken aback. What if I was overstretching my abilities and trying something I really shouldn’t be doing? Then, I realized it was more than just thinking you can, or can’t do something. It was more about the process. It didn’t matter if it took a little bit of time and I didn’t feel the need to complete the task I set out to do right then and there. Regardless of the difficulty of the exercise or challenge I had set fourth, it was more about the self-coaching and personal influence I gave myself to keep moving forward regardless of what got in my way. This process helped me take away the fear of trying something new.

The point was that I tried, I gave it my all. If I failed, I learned from the experience and did my best to not repeat mistakes. So, to keep yourself moving forward and maintain a positive attitude at the same time, here are three behaviors for a healthy and strong 2020.

Focus on Positive Affirmations I cannot tell you how critical this first step is, and ironically enough the hardest

46 | OR TODAY | JANUARY 2020

part about this is believing it. Don’t just write or tell yourself you're beautiful or you will squat more weight by the end of the year. You can’t just say these things, you must act on them. If you’re going to tell yourself you're beautiful go into detail. Is it your hair, nails, your attitude, what? If you’re going to say “I’m going to squat more weight by the end of the year.” What does that look like? Twenty pounds more? Fifty pounds more? Be specific and work toward it. Positive affirmations can go a long way to help remind you of the goal. Make sure you remind yourself daily.

Acting Toward Positive Affirmations Let’s use “I’m going to squat 40 pounds more by the end of the year” as a reference. If you set out a goal for yourself what are you doing daily to work toward it? Do you have daily workouts planned? Do you have accountability from others or is this more self-motivated? Did you plan out enough time throughout the day, week or month to ensure this goal can be achieved? These questions must be answered because if you fail to plan, then you’re basically planning to fail. For example, you can make sure you get three quality leg workouts in each week. One day focus on strength. One day focusing on range of motion or tempo. One day focus on endurance. However you decide to split it up or

plan it, just make sure you stick to it!

What Did You Learn? This action is a follow-up meeting you have with yourself. This can either be a daily or weekly checkpoint where you evaluate your progress. Don’t be afraid to be critical or fail. The point is to learn and adjust the plan accordingly, if needed. For example, let’s say you have a workout but your legs felt bad and your form was terrible. When you go back to the drawing board it’s important to correct your mistakes. So, maybe next week you try a yoga class instead of crushing your legs some more. Stretch the body more. Hire a trainer to make sure your form looks good or get a massage. Either way, the point is that you are looking within to make appropriate adjustments to your plan to ensure progress is made. Now, that is a recipe for success. Good luck with your training and goal setting and remember these three tips to stay on track.

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

Which Health Trends are Worth the Hype? By EatingWell hen the new big thing in

W health is, you know, healthy, we celebrate. (All hail, avocado toast on whole-wheat bread!) All too often, however, these fads are more style than substance. Here, are a few food obsessions we’re loving – and ones we were done with yesterday.

Nearly 60% of adults say they want to eat less meat and more plant protein. “You don’t even need to be vegan or vegetarian to get the benefits,” says Maya Feller, M.S., RD, an adjunct professor at New York University. Research shows that people who get 70% of their protein from plant sources have a lower risk of heart disease and stroke than those with meat-centric diets.

Love It: Fermented Foods

Love It: Sparkling Water

Kimchi, kefir, kombucha, yogurt, miso, sourdough – eaters are digging fermented and cultured foods. Consider kombucha: this $600 million global industry in 2015 is projected to rise to $1.8 billion in 2020. “Researchers increasingly believe probiotic bacteria in the gut are ‘driving the bus’ in many areas of physical and even emotional and mental health,” says nutritional therapist Jenna Hollenstein, M.S., RD, author of “Eat to Love.” “Fermented foods help keep these bacteria in balance – I’m a big fan.”

You used to see seltzer only in upscale restaurants. Now, even gas stations carry an ocean of options. Americans drank more than 800 million gallons of the stuff in 2018, almost triple what we sipped 10 years ago. Meanwhile, consumption of sugar-sweetened beverages (including soda) is down 25% in the last 20 years. We still love you, plain H2O, but if bubbly water gets more people to give up soda, we’re all for it: swapping your drink for one with no added sugars may help stave off weight gain, diabetes and heart disease.

Love It: Plant-Forward Eating We’ve been veggie-obsessed for years and love that plants are gaining mainstream traction as the star of the plate, with meat taking a supporting role.

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Over It: Functional Beverages Turmeric tonics. Mushroom smoothies. Protein coffee. Functional beverages like these are hot. Globally, we’ll spend $93 billion on them this year. Our

take: these drinks are fine as a bonus, but they’re not a replacement for a balanced diet. And check the nutrition – we found one 15-ounce bottle that packed 420 calories.

Over It: DIY Elimination Diets We all know someone who doesn’t do gluten or dairy or soy. And for some it’s a health necessity. But for anyone considering cutting out an entire category of food, it’s important to go about it the right way. Elimination diets are complicated and can have unintended consequences, like nutrient deficiencies, so they’re best undertaken with help from your doctor or a dietitian.

Over It: Bulletproof Coffee This java calls for up to 2 tablespoons of butter. Sure, we know that saturated fat isn’t a total devil, but this amounts to 60% of your recommended maximum for the day – and 200-plus calories – before you even sit down for a meal. EatingWell is a magazine and website devoted to healthy eating as a way of life. Online at www.eatingwell.com.

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OUT OF THE OR EQ factor

The Role of Fear in Conflict Resolution By daniel bobinski hink about some of the disagreements you’ve had with people. They can be tough to deal with, can’t they? Quite often when people have an opinion about something, they dig in their heels and don’t let go. This applies to everyone! Sometimes people dig in because they’re confident they’re right. Other times, people dig in because they’re afraid. Nobody likes to admit it, but yes, our fears can inhibit our relationships.

Last month, I talked about how emotions get formed and the impact they have on our thinking. This month, I want to address the emotion of fear and how it gets in the way of resolving conflict.

Five universal fears Everyone has fears, but below are five that get in the way of conflict resolution. Fear of criticism. Sometimes we know we need constructive feedback so we can learn where or how to improve, but even then, most people only endure it. It’s kind of like going to the dentist. We know the result will be good for us, but we still don’t like the process. If criticism is unsolicited, it can sting pretty bad. Fear of failure. When we place too WWW.ORTODAY.COM

much weight on what others think of us, or if we’re worried others will lose interest in us if we fail, we can become terrified of failure. This can be especially true when we’re in a conflict with someone, we don’t want to appear as though we lost an argument. Fear of rejection. Human beings are wired to belong. If we feel like people will reject us for disagreeing with them, it can inhibit good conflict resolution skills. Fear of not getting what you want. Oftentimes people do not move forward on something because they’re afraid the outcome won’t be what they expect. It’s different from fear of failure, but again, the fear can be so strong that a person doesn’t even try. Fear of losing what you have. Maybe you have something of value, whether it’s a position or a thing. If you’re afraid of losing it, it can prevent you from trying to resolve conflict. Being aware of our fears and how they impact and/or inhibit us is part of good self-awareness, which is the starting point for developing emotional intelligence. Then, knowing how fears impact and/or inhibit others is part of good social awareness, again, a key component in emotional intelligence. When we have disagreements with

others and each person is trying to be heard and understood, we can practice emotional intelligence by taking these likely fears into account and working to minimize them. If you’re interested, I’ve created a short instructional video on conflict resolution which has been posted at ORToday.com. If you take a few minutes to watch this video, you’ll learn some useful techniques for minimizing fears, and also the five steps I recommend for resolving conflict in a calm, productive way.

Daniel Bobinski, M.Ed. is a best-selling author and a popular speaker at conferences and retreats. For more than 30 years he’s been working with teams and individuals (1:1 coaching) to help them achieve excellence. He was also teaching Emotional Intelligence since before it was a thing. Reach him on his office phone at 208-375-7606 or through his website www.MyWorkplaceExcellence.com.

JANUARY 2020 | OR TODAY |

OUT OF THE OR nutrition

The Importance of Breakfast and Whole Grains By Charlyn Fargo ost of us can remember our mothers telling us breakfast is the most important meal of day. And Mom was right; it’s not a meal we want to skip. It literally “breaks the fast” and kick-starts our metabolism, helping burn calories throughout the day.

Breakfast also provides energy to get things done and focus. Studies have linked eating breakfast to good health, better memory, lower levels of lowdensity lipoprotein (bad cholesterol) and lower risk for diabetes, heart disease and being overweight. Skipping that morning meal can throw off your body’s rhythm of fasting and eating. (Hence, intermittent fasting may not be such a good idea after all.) When we get up in the morning, our blood sugar tends to be low; eating breakfast brings it up to normal levels. However, just over half of Americans eat breakfast daily, even though 8 in 10 Americans agree it’s the most important meal of the day, according to a survey by Quaker Oats. Can breakfast really help you lose weight? Some studies say yes. Researchers have found that on average, people who eat breakfast are thinner than those who don’t, perhaps because eating protein and fiber in the morning keeps the appetite in check. Stud-

52 | OR TODAY | JANUARY 2020

ies show that most people who lose weight and keep the weight off eat breakfast every day. We know that breakfast helps kids do better in school, and schools have responded by providing breakfast to students. Students who don’t eat breakfast have a harder time focusing, are more tired and don’t do as well on schoolwork. If you have a child who doesn’t like eating in the morning at home, pack something for the ride to school or in between classes. In our home, the solution was a smoothie that my daughter could drink on the ride to school. So how can you make breakfast a daily habit? Think outside the box for your morning meal. The Quaker survey found that nearly half of consumers prefer savory flavors for breakfast. So, ditch the notso-healthy doughnut for a vegetable frittata or an egg omelet in a cup that can be popped in the microwave. You can also add a sliced hard-boiled egg to avocado toast or spread a bagel with peanut or almond butter. Try for a mix of foods that have carbohydrates, protein, healthy fats and fiber: Greek yogurt with granola and berries, smoothies or a makeahead option of overnight oats, whole grain cereal with low-fat milk or a whole-grain protein bar.

All About Whole Grains There is a lot of confusion when it comes to grains. Should you eat grains? What is a whole grain? How do you cook them? Here are some answers from a Whole Grains: Breaking Barriers conference held in Boston. Grains worldwide provide nearly 50% of the calories eaten. All grains start out as whole grains, which contain all three original edible parts of the kernel. Processing can turn a whole grain into a refined grain, which means the bran and germ have been removed to make them easier to bake into bread or milder in taste or give them a longer shelf life. Without the bran and the germ, about 25% of the grain’s protein is lost along with at least 17 key nutrients. Processors add back some vitamins and minerals in the enriching process, but whole grains are healthier, providing more protein, fiber and up to 2 to 3 times more of vitamins and nutrients. Brown rice, for example, is an intact whole grain, while whole wheat flour has been milled. Whether a grain is still intact or has been cracked split or ground, it’s still considered a whole grain as long as all three of the original edible parts (the bran, germ and endosperm) are still present in their original proportions. WWW.ORTODAY.COM

You can identify a whole grain by the whole grain stamp on the package. Cooking whole grains is easy. You simply place uncooked grains in a pot, whether it’s rice, quinoa, barley or amaranth, then add at least twice as much water or broth, and bring the grain to a boil, then simmer. When it’s soft, it’s ready and you can drain any excess water off. Grains can simmer anywhere from 20 minutes to an hour, depending on the grain. Here are some ways to get more whole grains: 1. Substitute half the white flour with whole-wheat flour in your regular recipes for cookies, muffins, quick breads and pancakes. 2. Replace one third of the flour in a recipe with quick oats or old-fashioned oats. 3. Add half a cup of cooked bulgur, wild rice or barley to bread stuffing. 4. Add half a cup of cooked wheat or rye berries, wild rice, brown rice sorghum or barley to your favorite canned or homemade soup. 5. Use whole corn meal for corn cakes, corn breads and corn muffins. 6. Add three-quarters cup of uncooked oats for each pound of ground beef or turkey when making meatballs, burgers or meatloaf. 7. Stir a handful of rolled oats in yogurt.

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Charlyn Fargo is a registered dietitian with Hy-Vee in Springfield, Illinois. For comments or questions, contact her at charfarg@aol.com.

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OUT OF THE OR recipe

Miso Glazed Eggplant INGREDIENTS: • 4 slender Japanese eggplants • 2 tablespoons vegetable oil

Recipe

• 1/4 cup red or white miso • 2 tablespoons mirin or white wine • 1 tablespoon sake or water

the

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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. WWW.ORTODAY.COM

OUT OF THE OR recipe

Miso glazed eggplant

is a joy to cook f you can believe it, yet another edition of “The Joy of Cooking” has just come off the presses. This new generation includes 600 new recipes among their more than 4,000 revised and updated recipes. As I glanced through the book, I was amazed with all the new recipes, techniques and charts. This may be the most comprehensive cooking edition I have ever read. The original author’s great-grandson and his wife devoted nine years to revising and offering additional recipes to the book. Alongside the classics are multicultural recipes from countries such as Vietnam, Thailand and Mexico, as well as smoothies, pressure cooking and sous-vide

tips, to name a few. If you are thinking you need some help for cooking, invest in this book. And, by the way, this is the first “Joy of Cooking” edition to be offered as an eBook. One of the changes the authors made simplify recipes for today’s modern cooking. A good example is this easy and so delicious Japanese dish that I always order when dining out at Japanese restaurants. Now I can make it at home as a first course or side dish, depending upon what I am serving. Remember to look for slender Japanese eggplants that are all the same size. I also prefer to use the white or yellow miso for a milder flavor.

Miso Glazed Eggplant Makes 4 SERVINGS 1. 2. 3. 4. 5.

Position a rack in the center of the oven. Preheat the oven to 450 F. Lightly grease a baking sheet. Halve lengthwise: 4 slender Japanese eggplants Brush the cut sides liberally with: 2 tablespoons vegetable oil Roast cut side down on the baking sheet until the eggplant is slightly softened and just beginning to brown around the edges, 15 to 20 minutes. Meanwhile, mix in a small bowl until smooth: 1/4 cup red or white miso, 2 tablespoons mirin or white wine, 1 tablespoon sake or water 6. Remove the baking sheet from the oven, turn the eggplant halves over, and brush or spread the miso mixture onto the cut sides. Turn on the broiler, return the sheet to the oven, and cook until well browned and starting to char in spots, about 5 minutes.

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JANUARY 2020 | OR TODAY |

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CONTEST JA N UA RY

YEAR OF THE NURSE OR Today joins the World Health Organization in celebrating the 200th anniversary of Florence Nightingale’s birth and the Year of the Nurse in 2020. As part of the celebration, OR Today will feature perioperative professionals in a new contest! You could win a Bath & Body Works Gift Card! Every nurse is a leader! Please share a memory that illustrates a time when a nurse in your life or career served as a leader. Help us shine the spotlight on these leaders while at the same time encouraging others to lead. Please visit ORToday.com/Contest to share your story or email it to Editor@MDPublishing.com. Each entry will be entered into the contest.

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

– Life is a splendid gift it. ve ha u yo n he w e “Live lif l about it.” there is nothing smal le – Florence Nightinga

OR TODAY THIS MONTH'S CONTEST WINNER Submitted by:

Becky Gentry, R.N., C.O.A. . ., C.O.A y, R.N r t n e G Becky

56 | OR TODAY | JANUARY 2020

Director of Nursing

Georgia Cataract and Eye Specialty Center Carrollton, GA

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The News and Photos

OUT OF THE OR

that Caught Our Eye This Month

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HIGH-PROCESSED DIETS CAUSE WEIGHT GAIN Eating ultra-processed foods caused more calories to be consumed than when eating a minimally processed diet, according to researchers at the National Institutes of Health. The small study of 20 healthy adults (10 males, 10 females) ate an ultra-processed diet and a minimally processed diet in random order for two weeks each, totaling one month. Both diets had the same number of calories, sugars, fiber, fat and carbo-

hydrates, and participants could eat as much or little as they wanted. Those on the ultra-processed diet ate about 500 calories more per day and gained an average of two pounds, compared to those on the other diet, who lost two pounds. – Reprinted with permission from Environmental Nutrition.

PHYSICAL ACTIVITY, GOOD FITNESS IMPROVE CARDIAC REGULATION IN CHILDREN A recent Finnish study showed that more physically active and fit children have better cardiac regulation than less active and fit children. The study also showed that cardiac regulation was better especially in boys with better aerobic fitness and in girls with lower levels of sedentary time. The results, based on the Physical Activity and Nutrition (PANIC) Study conducted at the University of Eastern Finland, were published in the European Journal of Applied Physiology. Cardiovascular diseases cause a remarkable individual, public health and economic burden globally. Cardiovascular diseases have their origins in childhood, and physical activity has been found to prevent or postpone the development of these diseases. However, the mechanisms for the beneficial effects of physical activity are not completely understood. Improvements in cardiac regulation by the autonomic nervous system in response to physical activity have been proposed as one of these mechanisms. Nevertheless, there are few studies linking physical activity and aerobic fitness with

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cardiac autonomic regulation in children. Altogether 377 children aged 6-9 years participated in the study. Cardiac autonomic regulation was assessed by heart rate variability from electrocardiograms, physical activity and sedentary time by a combined heart rate and movement sensor, and aerobic fitness by a maximal exercise test on a bicycle ergometer. The data were adjusted for maturation, body fat percentage, waist circumference, fasting plasma glucose, plasma lipids and blood pressure. The researchers found that higher sedentary time and lower levels of physical activity and aerobic fitness were associated with poorer cardiac autonomic nervous system function in children. They also observed that particularly high levels of vigorous physical activity had a strong relationship to better cardiac autonomic nervous system function. Lower aerobic fitness in boys and higher sedentary time in girls were the strongest correlates of poorer cardiac autonomic nervous system function. These associations were independent of

other cardiometabolic risk factors. “Our study provides novel and valuable information as we were able to study the role of not only physical activity but also sedentary time, aerobic fitness and other cardiometabolic risk factors as correlates of cardiac autonomic nervous system function in children,” says Aapo Veijalainen, MD, PhD, from University of Eastern Finland. “We can conclude that the beneficial effects of a physically active lifestyle and good aerobic fitness go beyond traditional cardiovascular risk factors and all measures that get children to move must be supported.” – University of Eastern Finland

JANUARY 2020 | OR TODAY |

INDEX

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ALPHABETICAL Action Products, Inc.…………………………………………21

Capital Medical Resources……………………………… 50

Molnlycke Health Care……………………………………… 4

AIV Inc.…………………………………………………………………13

Doctors Depot……………………………………………………18

OR Today Webinar Series……………………………… 59

ALCO Sales & Service Co.……………………………… 49

Healthmark Industries Company, Inc.………… 26

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

AORN……………………………………………………………………17

International X-Ray Brokers…………………………… 53

SIPS Consults…………………………………………………… 49

Avante Health Solutions……………………………………31

Jet Medical Electronics Inc………………………………21

STERIS/Microsystems………………………………………… 5

C Change Surgical…………………………………………… BC

Key Surgical………………………………………………………… 9

Calzuro.com……………………………………………………… 47

MD Technologies Inc.………………………………………… 6

World Patient Safety, Science & Technology Summit………………………………… 47

ANESTHESIA

INFECTION CONTROL

PRESSURE ULCER MANAGEMENT

Doctors Depot……………………………………………………18

ALCO Sales & Service Co.……………………………… 49

ASSOCIATION

Healthmark Industries Company, Inc.………… 26

Action Products, Inc.…………………………………………21 Molnlycke Health Care……………………………………… 4

CATEGORICAL

AORN……………………………………………………………………17

CARDIAC PRODUCTS C Change Surgical…………………………………………… BC Jet Medical Electronics Inc………………………………21

CARTS/CABINETS ALCO Sales & Service Co.……………………………… 49 Healthmark Industries Company, Inc.………… 26 STERIS/Microsystems………………………………………… 5

CONFERENCE OR Today Live…………………………………………………… 40 World Patient Safety, Science & Technology Summit………………………………… 47

MD Technologies Inc.………………………………………… 6 Ruhof Corporation……………………………………………2, 3 SIPS Consults…………………………………………………… 49

INSTRUMENT STORAGE/TRANSPORT

RENTAL/LEASING Avante Health Solutions……………………………………31

REPAIR SERVICES

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

Capital Medical Resources……………………………… 50 Doctors Depot……………………………………………………18 Jet Medical Electronics Inc………………………………21

INVENTORY CONTROL

REPROCESSING STATIONS

Key Surgical………………………………………………………… 9

MD Technologies Inc.………………………………………… 6

LIGHTING/VIDEO PRODUCTION

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

STERIS/Microsystems………………………………………… 5

SAFETY

MAMMOGRAPHY

Calzuro.com……………………………………………………… 47

Key Surgical………………………………………………………… 9

International X-Ray Brokers…………………………… 53

Healthmark Industries Company, Inc.………… 26 Key Surgical………………………………………………………… 9

CS/SPD

MEDICAL IMAGING TABLES

MD Technologies Inc.………………………………………… 6

International X-Ray Brokers…………………………… 53

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

MONITORS

DISINFECTION

Doctors Depot……………………………………………………18

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

ONCOLOGY SERVICES

DISPOSABLES

Avante Health Solutions……………………………………31

ALCO Sales & Service Co.……………………………… 49

ONLINE RESOURCE

ENDOSCOPY

OR Today Webinar Series……………………………… 59

MD Technologies Inc.………………………………………… 6

Capital Medical Resources……………………………… 50

OR TABLES

SIPS Consults…………………………………………………… 49

International X-Ray Brokers…………………………… 53

STERIS/Microsystems………………………………………… 5

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

OR TABLES/BOOMS/ACCESSORIES

SURGICAL INSTRUMENT/ACCESSORIES

STERIS/Microsystems………………………………………… 5

Action Products, Inc.…………………………………………21

C Change Surgical…………………………………………… BC

STERIS/Microsystems………………………………………… 5

Healthmark Industries Company, Inc.………… 26

Healthmark Industries Company, Inc.………… 26 MD Technologies Inc.………………………………………… 6

FALL PREVENTION ALCO Sales & Service Co.……………………………… 49

FLUID MANAGEMENT MD Technologies Inc.………………………………………… 6

FOOTWEAR Calzuro.com……………………………………………………… 47

GENERAL AIV Inc.…………………………………………………………………13 Capital Medical Resources……………………………… 50

HOSPITAL BEDS/PARTS ALCO Sales & Service Co.……………………………… 49

58 | OR TODAY | JANUARY 2020

OTHER AIV Inc.…………………………………………………………………13

PATIENT MONITORING

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

STERILIZATION Healthmark Industries Company, Inc.………… 26 MD Technologies Inc.………………………………………… 6

SURGICAL Avante Health Solutions……………………………………31

Key Surgical………………………………………………………… 9

TELEMETRY AIV Inc.…………………………………………………………………13

AIV Inc.…………………………………………………………………13

TEMPERATURE MANAGEMENT

Avante Health Solutions……………………………………31

C Change Surgical…………………………………………… BC

Jet Medical Electronics Inc………………………………21

WARMERS

POSITIONING PRODUCTS

STERIS/Microsystems………………………………………… 5

Action Products, Inc.…………………………………………21

WASTE MANAGEMENT

Molnlycke Health Care……………………………………… 4

MD Technologies Inc.………………………………………… 6

X-RAY International X-Ray Brokers…………………………… 53 WWW.ORTODAY.COM

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