28
PRODUCT FOCUS TEMPERATURE MANAGEMENT
LIFE IN AND OUT OF THE OR
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CE ARTICLE PERIOPERATIVE PATIENT SAFETY
47
OUT OF THE OR DIET MAY HELP PRESERVE COGNITIVE FUNCTION
52
NEW CONTEST SHARE YOUR STORY
JULY 2020
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UNDERSTAFFING STAFFING
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OR TODAY | July 2020
contents features
38
UNDERSTAFFING AND INFECTIONS The Centers for Disease Control and Prevention (CDC) estimate that as many as 1.7 million hospital patients each year acquire an infection while being treated for other conditions. Studies indicate one contributing factor to HAIs is understaffing and nurse burnout.
27
TEMPERATURE MANAGEMENT MARKET GROWTH EXPECTED Reports indicate continued growth of the global patient temperature management market.
32
CE ARTICLE: PERIOPERATIVE PATIENT SAFETY The goal of this continuing education course is to provide evidencebased practice (EBP) information to educate perioperative caregivers in the management of hypothermia, hypoglycemia, hyperglycemia, and handover communication.
42
SPOTLIGHT ON: HANNAH MILLER, RN BSN OR nurse Hannah Miller moves to Good Samaritan Hospital's COVID-19 unit to provide patient care during pandemic.
OR Today (Vol. 20, Issue #7) July 2020 is published monthly by MD Publishing, 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290. POSTMASTER: Send address changes to OR Today at 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290. For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. © 2020
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INDUSTRY INSIGHTS 10 News & Notes 18 Medeon: Get Precise Predictable Laparoscopic Wound Closure - Fast 20 IAHCSMM: Insulation Testing Key to Reducing Electrosurgery Risks in the OR 23 CCI: An Update from CCI 24 Webinars: ‘Wonderfully Informative’ Webinar Addresses Burnout Concerns
27 M arket Analysis: Temperature Management Market Growth Expected 28 Product Focus: Temperature Management 32 CE Article: Perioperative Patient Safety
OUT OF THE OR
8 | OR TODAY | JULY 2020
ACCOUNTING Diane Costea
EDITORIAL BOARD Hank Balch, President & Founder,
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IN THE OR
42 Spotlight On: Hannah Miller, RN BSN 44 Fitness 47 Health 48 EQ Factor 50 Nutrition 51 Recipe 52 Pinboard
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OR Today Celebrates Nurses OR Today magazine 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 wants to feature nurses in a new contest! Every individual who submits an entry wins a gift card! To enter the contest, share a time when a nurse served as an inspiration to you or your team. This can be a peer, a mentor, an educator or anyone from the nursing profession. Help us shine a spotlight on these individuals. Please share your brief (1 to 3 sentences) contest entry at ORToday.com/Contest. •
Analysis: Telehealth to Experience Massive Growth Frost & Sullivan’s recent analysis, “Telehealth – A Technology-Based Weapon in the War Against the Coronavirus, 2020,” finds that the demand for telehealth technology is expected to rise dramatically as the COVID-19 pandemic continues to disrupt the practice of medicine and the delivery of health care worldwide. The telehealth market in the United States is estimated to display staggering seven-fold growth by 2025, resulting in a five-year compound annual growth rate (CAGR) of 38.2%. In 2020, the telehealth market is likely to experience a tsunami of growth, resulting in a year-over-year increase of 64.3%.
“The critical need for social distancing among physicians and patients will drive unprecedented demand for telehealth, which involves the use of communication systems and networks to enable either a synchronous or asynchronous session between the patient and provider,” said Victor Camlek, health care principal analyst at Frost & Sullivan. “However, all stakeholders need to remember that many people use the terms ‘telehealth’ or ‘telemedicine’ without understanding the ecosystem that is involved. This study will clarify the many components that are needed in order to implement telehealth.” •
Aspen Surgical Acquires Precept Medical Products Aspen Surgical Products Inc. has announced the acquisition of Precept Medical Products. Precept designs, manufactures and markets nonwoven, single-use disposable protective medical apparel that addresses infection control challenges faced by health care professionals, with a strong emphasis on the U.S. market. The Arden, North Carolina-based company is a leader in the U.S. surgical face mask market with its high-quality Fogshield brand and also offers a full line of procedure face masks, non-surgical isolation gowns, lab jackets, scrubs, cov-
10 | OR TODAY | JULY 2020
eralls, patient gowns, lab coats and cold therapy packs. The acquisition of Precept strengthens Aspen’s broad portfolio of medical disposables and patient and staff safety products sold into the acute care market. With Precept’s manufacturing facility in Agua Prieta, Mexico, and distribution warehouses in Douglas, Arizona, and Richmond, Virginia, Aspen gains approximately 200,000 square feet of manufacturing and distribution capacity, which can be leveraged for the company’s current portfolio as well as future growth initiatives. •
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INDUSTRY INSIGHTS
news & notes
Diversey Announces Efficacy Testing Against SARS-CoV-2 Diversey Inc. announced it will test several of its disinfectant products for efficacy against SARS-CoV-2, which causes COVID-19. These results will be submitted to the EPA for approval. “With a mission to protect and care for people every day, infection prevention is a major focus for Diversey,” said Mark Copeland, CMO for Diversey Inc. “Up until now, health care providers and others have been looking at the EPA’s Emerging Viral Pathogens Program for guidance, and more recently for claims against human coronavirus, on what products may work as disinfectants based on knowledge of similar pathogens. The Emerging Viral Pathogens Program is intended to bridge the gap between when outbreaks occur and novel viruses are available to test for specific product efficacy.” Diversey has partnered with Microbac Laboratories Inc. to test several of its products for effectiveness against
SARS-CoV-2. Microbac is a leading testing laboratory that offers antiviral and antimicrobial efficacy testing for various disinfectants, sanitizers, antiseptics and devices, against SARS, MERS and other microorganisms. Microbac is one of the only testing laboratories in the world certified by the Centers for Disease Control and Prevention to test the effectiveness of products against SARS-CoV-2 and viruses like it. This test data will not replace the EPA List N and guidelines for disinfectants for use against SARS-CoV-2 at this time. All products on this list meet EPA’s criteria for use against SARS-CoV-2, the virus that causes COVID-19. The testing will provide added assurance for specific efficacy against this virus. Until there is further EPA guidance, disinfectants found on the EPA’s List N should continue to be used according to their label instructions. •
CS Medical Announces Distribution Agreement CS Medical has announced a distribution agreement with AirClean Systems to offer the AirClean UV Light Box. The UV Light Box is just an example of when collaboration between companies can provide a solution in a time of need. Shortwave UV light has been used for years to decontaminate surfaces. The growing need to decontaminate N95 respirators has placed shortwave UV light as an alternative to other chemical based methods. AirClean Systems has been manufacturing workstations with shortwave light for more than 20 years. CS Medical scientists
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and engineers worked with AirClean Systems engineers to take the known research data and apply it. The collaboration between AirClean Systems and CS Medical has developed the UV light box for decontamination of N95 respirators. CS Medical and AirClean Systems have been working together for more than 10 years to deliver solutions for proper ultrasound probe storage with the CleanShield Ultrasound Probe Storage Cabinets. “The UV light box is another example of how small businesses can work together and provide solutions
to emerging health care problems. CS Medical is committed to helping health care in this time of need and with this partnership we provide another piece to the overall solution of risk reduction.” stated Mark Leath, president of CS Medical LLC. The UV Light Box is available in two widths and provides the decontamination of N95 respirators in a total cycle time of 60 minutes, 30 minutes per side. • For more information, contact CS Medical at (877) 255-9472 or email the team at sales@csmedicalllc.com.
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INDUSTRY INSIGHTS
news & notes
Ambu Launches Single-Use Cystoscope Ambu Inc. has introduced a new single-use cystoscope. The Ambu aScope 4 Cysto will give urologists immediate access to a single-use cystoscope that can be used for procedures such as bladder cancer surveillance, stent removal and other common cystoscopy procedures. Built on more than 10 years of single-use endoscopy experience, the launch of the aScope 4 Cysto enables Ambu to enter a large new market segment. Its new cystoscope will provide urologists a way to better manage their schedules and be more productive without worrying about device deterioration and other issues such as availability, reprocessing and costly repairs. “This is a game changer,” said Juan Jose Gonzalez, CEO of Ambu S/A, headquartered in Ballerup, Denmark. “Urologists will now have immediate
access to a high-quality scope that eliminates reprocessing and repairs. A urologist opens the package and immediately has a new scope offering peak performance with full articulation. They don’t have to wait and worry whether a scope will be available or whether it will work properly.”
The aScope 4 Cysto enables organizations to reduce costs on cleaning supplies, maintenance and repairs (and the associated long-term service contracts). It improves workflow and is portable, which makes it easier for doctors to deal with in-house consult procedures. •
UV Angel Announces Two New UV-C Light Products UV Angel has announced two new UV-C light devices to autonomously and continuously treat the air and surfaces for harmful bacteria, fungi and viruses. UV Angel’s newest products – UV Angel Air and the next-generation UV Angel Adapt – provide health care leaders and others with the tools for the fight against infectious diseases, including COVID-19. “We believe rapid deployment of UV Angel technology in hospitals around the country can provide immediate support to our health care workers on the frontlines of the fight against bacteria, fungus and viruses like COVID-19,” said Tom Byrne, CEO of UV Angel. “We are actively shipping our products to hospitals and military facilities throughout the country including a VA hospital in Pennsylvania and an Air Force Base Medical Center. While there are no environmental treatment technology silver bullets, it’s critical we provide these health care workers with as many layers of protection
12 | OR TODAY | JULY 2020
as we can to help keep them safe and in the fight.” UV Angel Air and the next-generation UV Angel Adapt use patented UV-C light treatment technology to automatically and continuously treat the air and surfaces. With a modern integrated design, UV Angel Air combines its proprietary UV-C air treatment system with standard in-ceiling lighting, requiring no staff interaction. Air is circulated through a sealed UV-C chamber, where it is treated with a high intensity UV-C light. The treated air is then returned to the room, creating a measurably healthier and safer environment. To treat frequently touched surfaces, UV Angel Adapt uses an intelligent, automated UV-C light treatment platform to continuously monitor and safely treat surfaces hundreds of times per day. UV Angel Adapt can be attached to keyboards, touch screens and a wide range of other frequently touched surfaces. •
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AAAHC Shares Alignment of Standards with New Industry Recommendations In conjunction with the Ambulatory Surgery Center Association (ASCA), the Accreditation Association for Ambulatory Health Care (AAAHC) is encouraging its accredited ambulatory surgery centers (ASC) to follow new guidance intended to further protect patients, families, and staff during the COVID-19 pandemic. Recently, ASCA released 10 recommendations for ASCs performing necessary surgeries at this time, and AAAHC has published a new tool to aid health care facilities with identification, isolation and information sharing measures. Based on the Centers for Disease Control and Prevention (CDC) guidelines, the ASCA recommendations and their alignment with AAAHC Standards reinforce prescreening measures, social distancing, appropriate personal protective equipment use and treatment, and post-operative screening to assess any COVID-19-related symptoms. “The joint guidance aids our accredited surgery centers by providing clear, actionable methods to limit the spread of infection,” said Noel Adachi, MBA, president and CEO of AAAHC. “By aligning AAAHC Standards with the recommendations from ASCA, we are helping our clients perform necessary gap analyses and keep quality of care top of mind.” The newly released information complements previous educational presentations by AAAHC, including recent webinars and other online resources related to the COVID-19 health crisis. • For more information on this guidance and other resources, visit www.ascassociation.org/covid-19-message or www.aaahc.org/covid-19.
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INDUSTRY INSIGHTS
news & notes
caresyntax Launches RESTART Program caresyntax has launched its RESTART program, a multi-faceted, multi-channel effort to support surgical leaders and hospital executives as they restart and ramp-up elective surgeries. The RESTART program intends to equip surgical leaders with the operational guidance to resume elective surgeries canceled or deferred due to COVID-19, in line with guidance from nonprofit leaders like the American College of Surgeons and the Association of periOperative Registered Nurses (AORN). At the heart of the program is the RESTART Playbook, a detailed plan built on advanced, patented analytic tools and customized for each hospital or ambulatory surgery center (ASC). caresyntax is proud to make the RESTART program available through the COVID-19 Healthcare Coalition. The coalition, led by Dr. John Halamka and Jay Schnitzer, is a private-sector led response that brings together health care organizations, technology firms, nonprofits and academia. Hospitals and ambulatory surgery centers may request their own RESTART Playbook online. In the first week alone, over 500 hospitals and ASCs across 47 states completed the simple questionnaire and requested a customized RESTART Playbook. caresyntax is also pleased to make its Periop Insight platform available free of charge to hospitals and ASCs as part of the RESTART Program. Facilities that provide additional historical and current surgical case data may use Periop Insight to significantly refine their Playbook and track and manage their performance as they ramp-up. As the exclusive analytics partner of AORN, caresyntax provides the industry standard tools for measuring and benchmarking perioperative performance to health systems, hospitals and ASCs of all sizes and types. In addition to directly supporting providers, caresyntax will make the insights gained on restarting surgery available through the COVID-19 Healthcare Coalition to inform government leaders, policymakers and industry partners as the United States works through the complex process of resuming elective surgeries. •
14 | OR TODAY | JULY 2020
Xenex LightStrike Robot Destroys SARS-CoV-2 in 2 Minutes Xenex Disinfection Services announced that its LightStrike pulsed xenon disinfection robot is the first ultraviolet (UV) disinfection technology proven to deactivate the actual SARS-CoV-2 (Severe Acute Respiratory Syndrome coronavirus 2). The LightStrike disinfection robot destroyed SARS-CoV-2, which is the virus that causes COVID-19, in two minutes. Testing was performed at the Texas Biomedical Research Institute, one of the world’s leading independent research institutes working exclusively on infectious diseases. Xenex Germ-Zapping Robots use a xenon lamp to generate bursts of high intensity, full germicidal spectrum (200-315nm) UVC light that’s more intense than sunlight. Different pathogens are susceptible to UVC light at different wavelengths. With full germicidal spectrum light, Xenex LightStrike robots quickly deactivate viruses, bacteria and spores where they are most vulnerable without damaging hospital materials or equipment. Xenex validated the efficacy of the LightStrike disinfection robot against live (not surrogate) SARS-CoV-2 in the biosafety level 4 (BSL-4) containment laboratory at Texas Biomedical Research Institute. Testing was also performed to measure decontamination of N95 respirator masks, as a result of health care facilities being forced to reuse personal protective equipment (PPE), and the robot achieved a 99.99% level of disinfection. Designed for maximum containment, BSL-4 labs offer a safe environment for scientists to study deadly pathogens for which there are no known treatments or vaccines. While SARS-CoV-2 is considered a BSL-3 level pathogen, Texas Biomed has both BSL-3 and BSL-4 resources and is able to utilize both in the study of COVID-19. Texas Biomed is home to one of fewer than 10 BSL-4 labs in North America and the only privately owned one. The Institute has both the expertise and resources to test against these pathogens. In 2015, also at Texas Biomed, Xenex proved the ability of the LightStrike robot to destroy the Ebola virus in 1 minute. •
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news & notes
BandGrip Joins Forces with Medline
KARL STORZ, Saphena Medical to Provide Integrated Solutions KARL STORZ Endoscopy-America Inc. has announced a new partnership with Saphena Medical to provide advanced instruments for endoscopic vessel harvesting (EVH). EVH is a revolutionary procedure that enables surgeons to obtain grafts for coronary bypass using a keyhole approach, without lengthy incisions. Dr. Albert Chin, cofounder of Saphena, pioneered the technology, which has enjoyed rapid and widespread adoption in the field. The introduction of Saphena’s Venapax device represented a major advance by enabling the surgeon to dissect, ligate and extract a vessel with a single instrument. The fourth-generation Venapax has been specifically constructed
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with a reinforced shaft and internal guides to fit a KARL STORZ telescope. It allows for simplified radial artery or saphenous vein harvesting with a shortened learning curve and a drastically reduced overall disposable cost. The partnership began with a pilot program at five hospitals and will continue to expand on a phased basis. “We are excited to join forces with such a dynamic and innovative partner. Our expertise in endoscopic imaging – which includes considerable experience in the cardiothoracic market – makes us the logical choice for advancing this EVH technology,” said Monica Ambrose, executive director of surgical marketing at KARL STORZ. •
BandGrip, innovator of the Micro-Anchor Skin Closure, has formed an exclusive sales, marketing and distribution agreement with Medline Industries Inc., a global manufacturer and distributor of health care products. BandGrip is a 3.5-inch by 1.5-inch bandage that offers a non-invasive method of wound closure without the use of needles or staples. Simple and intuitive, a wide range of health care professionals can apply the bandage without the involvement of the orthopedic surgeon. BandGrip uses non-invasive micro-anchors that grip the skin gently and securely to pull wound edges together and reduce wound closure time by more than 30%. The BandGrip Micro-Anchor Skin Closure is perfectly positioned as the wound closure of choice especially for surgeons who have adopted a more integrated telemedicine protocol into their post-operative care, according to a press release. Patients can remove their BandGrip Micro-Anchor Skin Closure from home, possibly preventing a return visit to their physician’s office or hospital in this age of social distancing. The terms of the agreement between BandGrip and Medline are undisclosed. •
JULY 2020 | OR TODAY |
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INDUSTRY INSIGHTS
news & notes
Getinge Online Improves OR Uptime Getinge recently introduced one of its latest connectivity solutions for acute care products. The digital platform Getinge Online enables hospitals to improve efficiency by using product data to gain insights and maximize uptime. Of the acute care products, the first ones to be connected to the new portal are the Getinge Flow Family anesthesia machines. Getinge Online, part of the service offering Getinge Care, is a digital platform to which hospitals can connect their Getinge products to transfer equipment data. “The idea is to analyze all available data and gain insights that will make life easier for our customers. It will help maximize product uptime by quicker remote trouble shooting and give access to remote expert support. This improves
efficiency and reduces costs, and with the incredible challenge of COVID-19 everyone is looking to find ways to solve issues remotely,” says Annica Jämtén Ericsson, director service and connectivity strategy at Getinge. The enhanced platform is designed in close collaboration with customers and the feedback has been very positive. The data from the anesthesia machines will also help enable the hospitals to reduce anesthetic agent usage and thus lower the environmental footprint. “Getinge Online is rooted in insights that connectivity will make a difference in health care and we will continue to add more products to Getinge Online, next in line are our Servo-u/n ventilators,” adds Annica. •
ChristianaCare Awarded Grant to Expand Telemedicine Program ChristianaCare has received a $714,000 grant from the Federal Communications Commission (FCC) to support telehealth services during the COVID-19 pandemic. ChristianaCare is one of only 17 health care providers in the U.S. and the first health system in Delaware to date to receive a grant under the FCC’s COVID-19 Telehealth Program. The funding is part of the recently enacted CARES Act, which appropriated $200 million to the FCC to support health care providers using telehealth during this national emergency. ChristianaCare will use the grant to support its COVID-19 Telemedicine Program. The program will expand existing telehealth capabilities by increasing broadband access to telehealth services for vulnerable and
16 | OR TODAY | JULY 2020
underserved residents in Delaware by providing devices and data plans. It will also offer on-site telehealth services to communities with high disease burden and challenges accessing virtual health services. Access to broadband telehealth services enables COVID-19 patients to safely remain at home in isolation instead of presenting to hospital facilities for further evaluation and care. In response to the COVID-19 pandemic, ChristianaCare established a comprehensive and sophisticated COVID-19 virtual provider visit and interactive telehealth program. The program leverages telemedicine visits with a provider for those individuals who have coronavirus symptoms or for those who have already tested positive and are symptomatic.
A key component of the program is the remote monitoring of these individuals by ChristianaCare’s CareVio care management program through secure text messaging. This ongoing monitoring connects patients with a registered nurse who monitors their condition several times per day to make sure the patient is improving. If the patient’s condition begins to deteriorate, a provider telemedicine visit is scheduled. Since the crisis began, CareVio has monitored more than 1,500 patients and more than 1,000 patients have had a telemedicine visit with the COVID-19 practice. CareVio has also called more than 4,400 patients following COVID-19 testing, ensuring they have a primary care provider and answering questions. •
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New OR and Interventional Integration Platform Announced FUJIFILM Medical Systems U.S.A. Inc. announced that the company has selected caresyntax as the supplier of Fujifilm Systems Integration using caresyntax’s proprietary operating room (OR) integration and workflow automation intelligence. As the health care industry continues to respond to today’s uncertainties, Fujifilm trusts this new partnership to aid hospital operations, improve workflow efficiencies of the interventional space and meet patient demand surges as deferred procedures are rescheduled. “As the only vendor that offers endoscopic imaging as well as modality solutions and enterprise-wide IT products – launching the Fujifilm Systems Integration business will allow Fujifilm to capture the full clinical value chain,” says Devon Bream, MPH, FACHE, global vice president endoscopy, general manager systems integration, FUJIFILM Medical Systems U.S.A. Inc. “We selected caresyntax as our supplier because the team has a demonstrated history in developing data-driven integration that provides the total visibility to achieve increased workflow efficiency, patient safety and surgical performance.” Together Fujifilm and caresyntax will develop a systems integration solution designed specifically for image and data integration in the operating room (OR/Hybrid OR) and endoscopy suite that will connect Fujifilm’s medical image capture products and Synapse brand viewing, storage and analytics technologies.
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INDUSTRY INSIGHTS
webinars news Medeon & notes
Get Precise, Predictable Laparoscopic Wound Closure – Fast all of my 10 mm to 12 mm incisions, suturing goes very smoothly every time, without the frustration sometimes experienced with other devices. Because AbClose is simple and semi-automated, the device minimizes variability between surgeons, skill levels and individual cases. Wound closure is easier in all cases, including those where the risk of hernia has traditionally been highest. That is an enormous advantage. When we can predictably and consistently close the fascia, we can prevent hernia and other potential complications.
By Kirby Tran, MD, MMM
Even widely used methods for laparoscopic port site closure can be frustrating and time-consuming. Many surgical specialties rely on abdominal laparoscopic procedures to speed healing while reducing downtime and pain compared to open surgery. For example, as an OB-GYN, I remove the uterus, ovaries, ovarian cysts and fallopian tubes and treat endometriosis and vaginal prolapse laparoscopically. At the end of any laparoscopic procedure, closure of the abdominal port site must be done successfully in order to prevent port site hernia, wound hematoma or infection. Optimally, we should be able to close the port site smoothly and efficiently, but even experienced surgeons can find the widely used suture passer frustrating and time-consuming for patients who are obese or offer other challenges. At the end of sometimes long and difficult surgeries, we struggle to see the right suture angle and fish around for sutures in order to properly close the fascia.
18 | OR TODAY | JULY 2020
Because AbClose is simple
AbClose is an elegantly and semi-automated, the simple device that allows fast, simple, and consistent device minimizes variability single-operator suturing. I have been using a new closure device called AbClose that enables me to close wounds very effectively and consistently without any assistance, regardless of the location or the abdominal wall thickness. Sutures are placed very precisely without any need to align the needle or fish for sutures. For
between surgeons, skill
levels and individual cases. Wound closure is easier for all cases, including those where the risk of hernia has traditionally been highest. WWW.ORTODAY.COM
INDUSTRY INDUSTRY INSIGHTS INSIGHTS Safe, predictable wound closure takes significantly less time, with higher surgeon satisfaction.
newsMedeon & notes
Because AbClose is so precise and preloaded, with no guesswork, I spend much less time on fascia closures. With my previous, commonly used suture passer, port site closure took about Kirby Tran, MD, MMM, 2-10 minutes, compared to just 1-2 minutes with AbClose. Shorter surgery time translates San Jose, California to benefits for patients, including decreased anesthesia time and risk of infection, both of which are especially desirable in morbidly obese patients or those with heart or pulmonary problems. In the hospital, where we continually refine our workflows in the OR, AbClose offers one more way to lend greater predictability to both procedures and OR scheduling. As a surgeon, efficiency means higher satisfaction. When I am fatigued, running late to clinic, or concerned about a patient’s complex medical needs, it’s discouraging to end surgery with a difficult closure. With AbClose, I know that I can always end on a safe, dependable and very efficient closure that prevents postoperative hernia. Learn more at https://www.abclose.com/.
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INDUSTRY INSIGHTS
IAHCSMM
Insulation Testing Key to Reducing Electrosurgery Risks in the OR By Peter Daigle, CBSPD urgeons rely on Sterile Processing (SP) technicians to provide clean, wellfunctioning instruments that will help result in good surgical outcomes. SP technicians must have knowledge, skills and understanding of how instruments are used and the critical need for proper inspection and testing prior to sterilization. This article addresses risks of electrosurgery and the importance of proper inspection and testing.
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Today, laparoscopic surgical instruments come in many different shapes and styles such as graspers, scissors, hooks and probes to complete specific tasks during the procedures. These instruments can also use electricity to cauterize tissue, allowing the surgeon to ablate (remove), sculpt, sever/cut, shrink/desiccate, coagulate and modify target tissue. A typical laparoscopic instrument consists of a handle/grip; electrosurgical attachment; 360-degree rotation knob; shaft; double-action jaw; and distal tip. When electricity is introduced to laparoscopic instruments through the electrosurgical attachment, insulation is needed on the instrument handle and shaft to ensure safety. Electricity flows through the
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instrument much like blood flows through veins and provides energy to the instrument’s tip; that energy is then directed to the intended targeted tissue. The type of energy present during these procedures is radio frequency (RF) electrical energy, which is measured in the unit of frequency called hertz (Hz). The current can only flow in a completed circuit. During a procedure, the electrical surgical unit is the active electrode and the patient is the return electrode. Current will always seek to complete a circuit and will always take the path of least resistance.
Understanding the risks Although laparoscopic surgery and electrosurgical capabilities have many benefits, there are potential risks, including unintended patient burns, shock to the surgeon and potential fires in the operating room (OR). During the procedure, the surgeon can only see 5% what is being viewed on the monitor; the other 95% is out of sight during the procedure. This poses an issue when electrical current is introduced to the instrument for tissue cauterization. If even a pin hole is present in the insulation, it will have an unintended electrical discharge that can burn an organ or tissue. Burns can cause hemorrhages, perforations in organs or intestines,
contamination from leaking bowels and vessel collapse. A hole in insulation can also release a stray electrical current that poses an electrocution risk to the surgeon, and surgical fires caused by electrical arcing (typically from a breach in the surgical instrument or cord) are another significant risk. Surgical energy is the ignition source in 90% of OR fire claims.1,2 There are two types of electrosurgical techniques used: monopolar and bipolar. With monopolar electrosurgery, the surgeon uses a probe electrode to apply the electrosurgical energy to the target tissue to achieve the desired surgical effect (such as cutting or coagulation). The current then passes through the patient to a return pad and then back to the electrical generator to complete the circuit. With the bipolar electrosurgical technique, a bipolar device – often a set of forceps – is used. The electrical current passes from one tip of the forceps through the target tissue to the other side of the forceps, then back to the generator. The electrical current is restricted to the tissue between the forcep's tips; therefore, the use of a return pad is not required. Insulated forceps can wear out anywhere along the instrument. The forceps’ distal end is often out of view of the surgeon. Forceps with damaged insulation pose the same patient safety WWW.ORTODAY.COM
IN 2020 risks as laparoscopic instruments. The cord supplying the electricity to the forceps must also not be damaged because it, too, can pose a burn or fire risk.
Insulation testing is critical for safety All laparoscopic instruments, insulated forceps and cords must have their insulation tested to ensure there are no breaches. Most of these breaches cannot be seen by the naked eye; therefore, an insulation integrity tester should be used. All electrosurgical instruments must be tested in the preparation and packaging area prior to undergoing sterilization.3 Proper insulation testing takes only minutes. A laparoscopic insulation tester is a low-frequency, high-voltage generator that delivers the voltage to an inspection electrode. As the electrode moves over the insulation and a pin hole or bare spot is encountered, a small current flow will create a visible (non-hazardous) spark at the point of contact, which then triggers a visible and audible alarm in the unit. If an instrument fails insulation testing, the device must be immediately removed from service until repaired or replaced. Note: Many laparoscopic insulation testers are available on the market and it is essential that each health care facility does its research and purchases the one best suited to its needs. It is important to never place any sharp instruments in a set that may come in contact with insulated instruments and possibly cause damage. WWW.ORTODAY.COM
Even if the laparoscopic instrument does not have cauterization capabilities, it also must be tested because even a small insulation crack can allow bioburden to become lodged in the instrument. Bioburden can pose a risk for a hospital-acquired infection.
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Conclusion Surgical procedures will not be successful without SP technicians’ knowledge of proper care and handling of surgical instruments, including electrosurgical instruments. Insulation testing must be part of every SPD’s quality assurance program. This will help drive best practice, improve safety in the OR and promote positive patient outcomes. Peter Daigle serves as sterile processing supervisor at the University of Connecticut Health Center.
References 1. Overbey, DM, Townsend, NT, Chapman, BC, Bennett, DT, Foley, LS, Rau, AS, Yi, JA, Jones, EL, Stiegmann, GV, Robinson, TN. Surgical energy-based device injuries and fatalities reported to the food and drug administration. J
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Am Coll Surg. 2015; 221:197–205.e1 2. Smith, LP, Roy, S. Operating room fires in otolaryngology: Risk factors and prevention. Am J Otolaryngol. 2011; 32:109–14 [Article] [PubMed] 3. Association of periOperative Registered Nurses. 2010 Perioperative Standards and
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INDUSTRY INSIGHTS
CCI news & notes
An Update from CCI By James X. Stobinski, PhD, RN, CNOR, CSSM (E) wrote this column last month as we were just beginning to realize the full impact of the COVID-19 pandemic. The American health care system continues to wrestle with unprecedented demand for critical care resources in early May (as I write this column). The staff at Competency and Credentialing Institute (CCI) are still working from home to address the needs of our perioperative nurse certificants. It is difficult to maintain regular communication under these circumstances as we consider the disruption faced by many of our nurses. I would like to update the perioperative community on our efforts to be ready when the COVID-19 pandemic diminishes and we can resume normal operations.
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First, let me reassure you that the full complement of CCI staff remains at work and available to address your certification and professional development needs. The credentialing team continues to work from home, but we have not experienced significant degradation of our services to certificants. Our response times remain consistent with pre-pandemic levels as we answer WWW.ORTODAY.COM
inquiries regarding recertification and re-scheduling of testing appointments. In-person testing facilitated by our partner Prometric remains shut down with phased reopening beginning June 1. The shut down of facilities may continue beyond that date due to local restrictions. When testing facilities do reopen there will likely be diminished capacity for some time as social distancing requirements will be in effect that will require additional spacing between testing candidates. We estimate that testing sites may work at 50% of capacity for some time and that will decrease the availability of options for testing seats. In anticipation of decreased capacity for in-person testing CCI is working closely with Prometric to increase the availability of Remote Secure Proctored Examinations which can be done from the home of the tester. Approval has been secured from our accrediting agencies, the NCCA and ABSNC, to offer remote exams for the CNOR, CSSM and CNAMB credentials once the capacity is available. We have completed pilot testing and anticipate making remote testing more widely available. This testing should, at present, be considered a supplement to the limited in-person testing. We also will not mandate remote testing for any of our test takers. All nurses testing will have the option
to re-schedule to a future date when additional in-person testing is available and CCI staff will facilitate the re-scheduling process in tandem with the Prometric team. The launch of the ambulatory surgery credential (CNAMB) has been pushed back to later in 2020. CCI will re-open registration for this exam during July and August. The inaugural testing period will be the entire month of September and full-time, year-round testing will then resume in the first quarter of 2021. A CNAMB Prep Course will be available in July with a recorded version of the course being the first offering. To increase the diversity of professional development offerings, CCI continues to develop our suite of microcredentials and certificate of mastery programs. That work is facilitated by several partners. The selection of microcredentials will continue to grow with additional offerings coming online in mid-2020. The CCI staff will continue to build up our programs and learning activities as we await the easing of the COVID-19 crisis. We continue to be impressed by the stories of sacrifice and adaptation as perioperative nurses do their part in response to the extraordinary demands placed on our health care system. Please stay safe and take good care of yourself and your families. JULY 2020 | OR TODAY |
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INDUSTRY INSIGHTS
news & notes webinars
WEBINAR SERIES
‘Wonderfully Informative’ Webinar Addresses Burnout Concerns Staff report he April 16 OR Today webinar “Nurses Eat Their Young … Because They Are Starving” was eligible for one (1) continuing education (CE) hour by the State of California Board of Registered Nursing.
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This 60-minute webinar featured Michelle Lemmons, RN, BSN, PHN, Clinical Educator-OR at Key Surgical. Lemmons discussed the current and historical occurrence of health care burnout, suicide and depression, how the COVID-19 pandemic is highlighting these problems, regulatory bodies’ statements and interventions, and what health care organizations, managers and individuals can do to help decrease these statistics. The webinar, which was sponsored by Key Surgical, attracted 188 attendees for the live presentation. A recording of the webinar is available at ORToday.com. A post-webinar survey resulted in great feedback with many attendees praising the session. “I found this presentation very interesting because myself being a newer nurse had to deal with the struggles of ‘being ate’ by older nurses who weren’t very friendly and did not have interest in showing or helping me learn. It was a sink-or-swim situation
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" As a new nurse, it was helpful to hear that some of the things I experienced as a brandnew nurse are very real and happen often to new nurses.” – R. Kilby, RN most days, so I do everything I can when I see a nursing student or new nurse to help and encourage them. It’s very important to build the confidence of a newer nurse,” shared S. Kidwell, RN. “I thought the stats on depression and suicide were staggering! Thank you for bringing that to light,” said A. Gray, CST. “This webinar was very helpful for learning how to communicate and understand burnout and stresses that seasoned nurses go through. As a new nurse, it was helpful to hear that some of the things I experienced as a brandnew nurse are very real and happen often to new nurses,” said R. Kilby, RN. “Content was very relevant to the OR. It can be a stressful learning situation being a new nurse in the OR. It’s a specialized area with a lot to learn. My OR has a high staff turnover, and rarely do you get new staff that have OR experience. It’s understandable that nurses get tired of training new staff constantly. I try to remember
how overwhelming it can be starting a new position or how I felt straight out of school being a new nurse,” said Charge Nurse J. McDowell. “This was so helpful to get insight into what it’s like for the people on the front lines, especially during COVID-19. Too often we hear stories of health care companies forgetting to put the people first. It was particularly timely for me to hear about how each nurse or tech can grow together and look out for one another in such trying times,” said T. Hazen, sales manager. “It is nice to know that other people experience the same issues throughout the system. We are not alone and can help each other out,” said R. Morris, DCM supervisor. “Wonderfully informative and spoke from experience and the heart,” said J. Zareminski, SPD technician. “Speaker was very knowledgeable. A lot of great points addressed, especially related to the stress of COVID-19. Speaker’s experience is reflective of the discussion points, esWWW.ORTODAY.COM
pecially on bullying among healthcare workers,” shared I. Stranz, RN. “Relevant information for clinical instructors who are to motivate students in clinical rotation sites. Bullying towards students causes some students to not want to explore the field of nursing. They constantly discourage students, making them feel that they are in the way, when they only want to learn and observe the health care professionals,” Department Coordinator Health Services D. Austin said. “It was refreshing to listen to something with less emphasis on COVID-19 and more on human interaction! Delightful speaker,” Perioperative RN C. Evenson said. “Different topic and very timely. Not specific to my area of practice, but COVID-19 burnout is prevalent even for me, in a different way as a consultant,” said P. Segal, president. 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 sponsor:
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Choose air-free patient warming and avoid the risk of aerosolizing pathogens Warm your patients safely in ORs, ERs and ICUs, and avoid the risk of aerosolizing airborne pathogens. Active patient warming is a critical therapy when hypothermia is a concern. As a result of the COVID-19 pandemic, ORs, ERs and ICUs are choosing to warm patients without mobilizing pathogens. Research has shown that forced-air warming can spread airborne contaminants.1-13 HotDog blankets and mattresses are encased in an anti-microbial shell and are easily cleaned between uses. HotDog blankets and mattresses are designed for reuse, so there are no resupply issues. The HotDog system warms patients above and below simultaneously for more effective warming without blowing air.
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market analysis
Temperature Management Market Growth Expected Staff report he “Patient Temperature Management Market Outlook & Projections, 20192027” report from ResearchAndMarkets.com predicts growth through 2027.
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Patient temperature management systems are used to control and manage the body temperature of patients. These systems bring the temperature down by cooling the body through therapeutic hypothermia and then maintain the body at the normal temperature. “The market for patient temperature management for cooling systems is anticipated to grow at a CAGR of 6.34% over the forecast period, i.e., 2020-2027. The significant growth can be primarily attributed to the growing cases of cardiovascular diseases, neurological diseases and others that require effective temperature management,” according to the Business Wire press release. “The market is segmented by cooling systems, by components, by application, by end user and by region,” the press release adds. “The segment for cooling systems is further segmented into conventional cooling systems, surface cooling systems, intravascular cooling systems and transnasal cooling systems. Out of these, the surface cooling segment was estimated to hold 48% of the total market share in 2018 and is predicted to grow at the highest rate during the forecast period as a result of increasing usage of surface cooling systems such WWW.ORTODAY.COM
as blankets and pads containing cooling fluids either in the form of air or water." “Based on application, patient temperature management market for cooling systems is segmented into cardiology, neurology, orthopedics, pediatric and others, out of which, the cardiology segment is projected to hold a significant market share and reach a market value of $335.15 million by 2027,” Business Wire reports. “The growth can be attributed to rising incidences of heart disorders such as stroke, myocardial infarction and cardiac arrest among others.” “On the basis of geography, the market is segmented into North America, Europe, Asia Pacific, Latin America and Middle East & Africa. The largest share was held by the market in North America while the highest growth over the forecast period is anticipated to be observed by the market in Asia Pacific with a CAGR of 7.34% during the forecast period,” according to the release. “The market in Asia Pacific is led by China with a market value of $82.01 million in 2018. The demand for patient temperature management systems is high on account of technological advancements and rising incidences of various disorders.” A Globe Newswire report also predicts market growth. “The global patient temperature management market is estimated to grow at CAGR above 7.5% over the forecast time frame and reach the market value around $7.8 billion by 2026,”
Globe Newswire reports citing Acumen Research and Consulting. The increasing amount of surgeries is expected to accelerate the demand for temperature control equipment, according to the report. There are increasing numbers of surgeries conducted with increasing incidence of cardiac arrest, and other chronic heart diseases. “This increase is expected to drive the need for patient temperature control in order to prevent negative brain impacts,” Globe Newswire reports. “For cancer patients, patient warming devices are also used as chemotherapy and radiation additives for more successful outcomes. In addition, newborns in neonatal treatment are probably subject to changes in temperature, which keeps them in incubators for a normal body temperature. The above variables drive demand for temperature surveillance equipment.” “Modern temperature management systems are increasingly needed as demand for standard heating and cooling equipment is increasing,” the report adds. “During the prediction era, the introduction by leading market players of a broad spectrum of ground warming and cooling technologies will have a positive effect on the patient temperature leadership industry. Over the years blood and fluid thermal control systems have also developed and can be implemented by circulating hot or cool saline through a catheter in the patient’s body.” JULY 2020 | OR TODAY |
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product focus
Encompass Group
Thermoflect Transport Cocoon Thermoflect Heat Reflective Technology helps maintain normothermia and prevent hypothermia by reflecting and containing the patient’s infrared heat. It creates a warm cocoon of air and prevents convective heat loss (wind chill). Maintaining normothermia and preventing hypothermia is essential to improved outcomes and reduced risk of surgical site infections. The Thermoflect Transport Cocoon is specifically designed as the first line of defense for trauma patients. It features a super absorbent core to contain and measure lost fluids, a full-length Velcro closure to allow easy access and is individually vacuum packaged for storage. • For more information, visit www.thermoflect.com.
Attune Medical ensoETM
Attune Medical’s ensoETM modulates and controls patient temperature through a single-use silicone tube inserted into the esophagus, similar to a standard gastric tube, and connected to an external heat exchange unit. Positioned at the core, next to the heart and great vessels, water circulates inside the closed-loop system to efficiently warm or cool a patient. Unlike surface warming devices, the ensoETM’s internal placement won’t impede patient access during surgery, and allows gastric decompression and administration of fluids and medications. The ensoETM works with existing heat exchangers and can be rapidly placed by most trained health care professionals. The ensoETM is the only device cleared for use in the esophagus for wholebody temperature modulation. •
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IN THE OR
product focus
Augustine Surgical Inc.
HotDog Patient Warming System You have never been more concerned about aerosolizing pathogens, but you still need to warm your patients. Even though air-based warming is out, we’ve got you covered. HotDog’s patented technology is a safe air-free patient warming alternative. It’s the only system that warms above and below the patient simultaneously for a versatile and more effective warming solution. In multiple trials, HotDog has shown a 96.2% normothermia rate. Plus, reusable HotDog blankets and mattresses reduce warming costs. In steep Trendelenburg, HotDog works with the WaffleGrip Positioner to combine warming and reliable patient securement in one, easy-to-use, less expensive system. • For more information, visit www.hotdogwarming.com.
C Change Surgical
SurgiSLUSH SurgiSLUSH 2-liter and 4-liter automated slush freezer systems slash equipment costs and deliver protected sterile slush when and where it is needed. Press one button and walk away. While your team attends to other priorities, SurgiSLUSH freezers automatically produce and maintain smooth slush with 24-hour slush containers ready when needed. Portable containers protect sterility and eliminate slush drapes and slush bags. Covered, tamper-evident containers verify sterility before every use for every patient in rooms or out and hands-free during complex procedures. •
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product focus
MAC Medical
Blanket & Fluid Warming Cabinets The D-Series (Data Logging) Warming Cabinets provide independent, digitally controlled heating chambers that offer actual temperature and set point displays. The Ethernet/Wi-Fi capable TS-Series (Touch Screen) Warming Cabinets offer unparalleled technology by allowing remote connectivity to your warmer (via smartphone app) and giving you control of your warmer wherever you are. MAC Medical warming cabinets undergo stringent testing procedures during the manufacturing process to assure a long life, the highest quality and accurate temperature settings. •
ZOLL
Thermogard XP (TGXP) Intravascular Temperature Management System ZOLL’s Thermogard XP (TGXP) intravascular temperature management system provides health care professionals with the power and control needed to rapidly and accurately manage the core body temperature of critically ill or surgical patients with warming and cooling applications. It offers superior clinical efficiency in reaching and maintaining target temperature,1-7 while decreasing demands on nursing staff and reducing nursing workload by 74%.8 A variety of standard central venous catheters (CVCs) and unmatched control regardless of target temperature enable tailoring the treatment to the individual. • 1. Idris AH, et al. Circulation. 2012; 126:LBBS-22813-AHA. 2. Hoedemaekers CW, et al. Critical Care. 2007;11:R91. 3. Knapik P, et al. Kardiologia Polska. 2011;69(11):1157-1163. 4. Mayer SA, et al. Critical Care Medicine. 2004;(3)212:2508-2515. 5. Diringer MN, et al. Critical Care Medicine. 2004;(32)2:559-564. 7. Heard KJ, et al. Resuscitation. 2010;81:9-14. 8. Horn CM, et al. Journal of Neurointerventional Surgery. 2014 Mar;6(2):91-95.
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IN THE OR
product focus
Gentherm
WarmAir Patient Warming System Gentherm’s WarmAir patient warming system is a compact and quiet unit that delivers gently moving warm air using a low velocity blower. All air is filtered through the WarmAir unit and the FilteredFlo blankets. With built-in safety monitoring systems, caregivers will be alerted if the temperatures exceed or fall below temperature settings, providing further protection to a patient. It helps keep patients comfortable before and after surgery and maintains body temperature during surgery. Gentherm uses Filtered Air Warming which is a unique patented design of a FilteredFlo blanket that permits usage of a lower velocity blower to supply gently moving, filtered air. •
Getinge
GET1850BL Combination Blanket/ Fluid Warming Cabinet Getinge’s stainless steel blanket, fluid and combination warming cabinets outperform traditional warming technology. Patented, intelligent, multi-zone heating technology prevents the overheating of blankets that creates the potential for scorching and discoloration. The small standalone blanket warming cabinets feature no lint-clogging fans or moving parts to reduce the incidence of repairs. Getinge GET1850BL Combination Blanket/Fluid Warming Cabinet with separate programmable digital controls ensure that blankets and fluids are safely and accurately heated to recommended temperatures. It has a 30-40 blanket capacity; 30 one-liter bottles, 24 one-liter bags with basket or 36 one-liter bags without basket. •
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CE614
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continuing education
Perioperative Patient Safety: Hypothermia, Hypoglycemia, Hyperglycemia, and Hand-overs By Anita M. Hornacky, BS, RN, CST, CNOR ccording to the Centers for Disease Control and Prevention (CDC), more than 54.1 million people undergo surgery in hospitals annually in the United States.1,2 Many patients suffer from preventable events, causing injury and even death when perioperative team members lack knowledge to prevent adverse outcomes. Following EBP information and guidelines can reduce patient injuries and SSIs.
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The treatment of surgical site infections (SSIs) is reported to cost $3.5 billion to $10 billion annually.3 Patients readmitted to a hospital with a SSI stay an average of 9.7 days and cost an additional $700 million per year.3 Medicare and Medicaid are no longer paying for treatment of preventable injuries or SSIs. The Joint Commission has in place National Patient Safety Goals to provide guidance on preventing surgical site infections. The Centers for Medicare & Medicaid Services (CMS), in collaboration with the CDC, implemented the Surgical Care Improvement Project (SCIP), which sets guidelines recommended to prevent SSIs. These organizations have created guidelines for recommended practice as a starting point, which are only successful if followed. Measures are taken to help track compliance with national standards based on current EBP to promote the prevention
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of injuries related to surgery, SSIs, and patient safety. Guidelines and standard recommendations cover many topics in the operation room (OR). The management of these four important topics have been selected for discussion: hypothermia, hypoglycemia, hyperglycemia, and hand-overs in the perioperative setting.
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 37 to learn how to earn CE credit for this module.
Problems in Current Practice
Goal and objectives
The U.S. government and organizations such as the World Health Organization (WHO), Association of periOperative Registered Nurses (AORN), CMS, CDC, and The Joint Commission (TJC) have taken steps to promote patient safety. TJC established the National Patient Safety Goals (NPSG), an attempt to standardize perioperative patient care. These goals have reduced the number of adverse events and are updated each year according to the latest statistics and patient health care trends. Standardized guidelines and checklists document activities in the patient chart. Some of the 2019 NPSG include:4 Patient identification measures Improve communication Infection prevention Identification of safety risks Implement guidelines to prevent surgical mistakes WHO created an established 19-item surgical safety checklist that has demonstrated a reduction in morbidity and mortality around the world. Organizations
The goal of this continuing education course is to provide evidencebased practice (EBP) information to educate perioperative caregivers in the management of hypothermia, hypoglycemia, hyperglycemia, and hand-over communication. After studying the information presented, you will be able to: •
List risk factors associated with hypothermia and interventions for prevention
•
Identify signs for hypoglycemia
•
List physiologic parameters for the hyperglycemic patient
•
Describe an effective perioperative hand-over
such as AORN have adopted the checklist and modified it to fit their individual needs. Universal protocol helps ensure the correct patient undergoes the correct surgery on the proper body part. The World Federation of Societies of AnaesthesiWWW.ORTODAY.COM
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continuing education ologists urges practitioners to follow the International Standards for Safe Practice in Anesthesia. These organizations base their guidelines on EBP, which serves as the underlying rationale for appropriate actions and is the key to safe practice. This course covers hypothermia, hypoglycemia, hyperglycemia, and hand-over communication. Each topic includes an overview of EBP information that health care providers can apply to reduce patient harm from adverse events. The ability to apply the information depends on a solid understanding of EBP in the perioperative setting.
Evidence-Based Practice EBP is a problem-solving approach to delivery of care that incorporates the most current and best evidence from research. Research is evaluated for proof that supports the rationale for actions. Studies are conducted constantly, producing new research. Every health care provider should question why an action is performed and if there is a better or safer way of completing a task based on new research and supporting evidence. Many health care providers complete tasks out of habit, which may no longer be supported by current data. The fastpaced environment of the preoperative area, OR, and Post-Anesthesia Care Unit (PACU) allow little time for health care providers to seek evidence-based information. Therefore, nurse educators need to keep current on the latest research and help implement new guidelines into the daily practice of the health care staff. Questioning practice and determining if there is a need for change begins the process of EBP. Asking a clinical question about a practice and searching for research-based resources increases knowledge and helps with critical evaluation of the evidence for usefulness and importance in the perioperative setting. The next step is designing a clinically applicable plan. Change is never easy and needs support from health care providers, who must commit to the change. Administrators need to provide evidence for the WWW.ORTODAY.COM
proposed change and additional resources whenever introducing new products, equipment, or policies that may require employee training or additional personnel. Providing evidence and additional resources for the change in policy, product, or equipment will build support for the change during the implementation from all staff members, including physicians and anesthesia providers, resulting in successful implementation. EBP is not exclusive to one setting, and everyone plays a vital role in its promotion.
Hypothermia A common complication of surgery is hypothermia, or the reduction of core body temperature to less than 96.8º F. A long-term study of 143,157 noncardiac patients from April 2005 to February 2013 at the Cleveland Clinic documented that core temperature declined in the first hour of anesthesia and increased thereafter. Sixty-four percent of patients reached a core temperature below 98.6º F within 45 minutes after induction. Nearly 29% reached a core body temperature of below 95.9º F. Only 7.3% of patients had core body temperatures less than 95º F at 71 minutes. The study found that 91% of patients warmed with forced air recorded core temperatures above 98.6º F by the end of the surgical procedure.5 This lengthy study documented core body temperature and the relationship to surgical complications. New guidelines and practices have been updated from ongoing studies. For the surgical patient, hypothermia can be traced to heat loss related to the cold surgical environment, the effects of anesthesia-induced thermoregulation impairment (general and regional anesthesia), prolonged exposure of skin, cold prep solutions, cold irrigation and IV fluids, and exposed skin after draping.6 Hypothermia can lead to potential myocardial complications, coagulopathy, acidosis, surgical wound infections, reduced drug metabolism (including muscle relaxants), increased need for blood transfusion, and prolonged recovery. Hypo-
thermia also is associated with increased mortality in trauma patients related to blood loss, exposure to the environment, and rapid infusion of cool fluids.5
Who is at Risk for Hypothermia?6 Adults older than age 55 years with body mass index (BMI) of less than 25 kg/m2 Patients with a preoperative hemoglobin level of less than 1.4 g/dL Patient’s whose surgery lasts more than four hours Burn patients Patients with chronic renal impairment Infants Patients who are critically ill Patients with a history of cardiac surgery or organ transplant Patients with neurologic disorders
Factors influencing the severity of potential hypothermia include: Low body weight due to limited fat and muscle Large body surface to weight ratio in infants Metabolic disorders that limit heat production or a proper response to ambient air temperatures Antipsychotic or antidepressant use that impairs thermoregulation Pneumatic tourniquet use after it is released and heat from the core moves to the extremity Temperature in the surgical environment that causes heat lost through radiation, convection, conduction, or evaporation Open-cavity surgery in a cool environment Infusion of cold IV fluids or blood Irrigation with cool solutions as heat transfers to the solution from the body
Nursing Across the Spectrum of Care It requires a team effort to minimize hypothermia’s adverse outcomes. In the preoperative area, the nurse assesses the patient’s risk for hypothermia by evaluating vital signs, laboratory results, type of anesthesia, and general health status. JULY 2020 | OR TODAY |
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continuing education SCIP measures require the preoperative nurse to record the patient’s temperature and warm patients before surgery based on need. The goal is to place the patient in a normothermic state before, during, and after a surgical procedure. The hypothalamus and skin regulate the body temperature. Vasoconstriction can occur if a patient’s temperature drops, reducing tissue perfusion and leading to complications and SSIs. Overheating a patient can cause vasodilation and fluid imbalance caused by sweating. The body may cool during the evaporation of sweat causing hypothermia. If muscle relaxants are given by the anesthesia provider, the patient may lose the ability to shiver, which is the body’s defense to generate heat. AORN recommends that nurses warm patients with an active warming device with forced air. AORN created a Prevention of Perioperative Hypothermia (PPH) Tool Kit. This guide describes steps to prevent perioperative hypothermia.6 The preoperative nurse can minimize hypothermia with the use of a forced air gown, which can be used in the OR and PACU. Warm cotton blankets have not proven to prevent hypothermia because they cool quickly. The perioperative nurse also can minimize heat loss and maintain normothermia by warming the OR room temperature. For the average adult, the room temperature should be between 68º F to 75° F. Neonates, infants, and the critically ill should be in a room where the temperature remains between 78.8° F and 85° F.6 This may be uncomfortable for the surgical staff, but can reduce the incidence of hypothermia. Once the patient is actively warmed with a forced air gown or other warming device, the room temperature may be adjusted if the patient is normothermic. It is good practice to keep the patient covered before a procedure exposing only the surgical site, if possible, to retain heat as well as patient dignity. Active warming devices are common in the form of a gown, drape, mattress, or pad. Specialized gowns are designed
34 | OR TODAY | JULY 2020
to attach a hose that delivers warm air from a warming unit. Many ORs keep special body warming drapes that work the same way but may be positioned for the upper or lower body according to the surgical site. You must take care to not let the hose touch the patient’s skin because it can overheat and cause a contact burn. Assess the patient’s skin before and after a procedure and document the condition. Warming units maintain multiple heat settings and should be set according to the patient’s desired body temperature. During long procedures, the patient’s temperature should be monitored constantly. As such, the warming device setting may need to be adjusted according to temperature. In some cases, where there is exposure of a large area of skin, the recommendation may be to use a warm water mattress or other warming pad under the patient during the procedure. Other active warming devices include: radiant warming, energy transfer pads, and carbon fiber resistive warming. When using any warming device, be sure to follow the manufacturer’s instructions. It is not recommended to warm the OR bed with the forced air hose placed under the sheet prior to the arrival or draping of the patient. This practice can disperse microorganisms into the air that may contribute to SSIs. Observation of temperature occurs in conjunction with the anesthesia provider, who can obtain continuous intraoperative core temperature measurement depending on the type of surgery, by oral, skin, temporal artery, axillary, rectal, pulmonary artery, distal esophagus, tympanic membrane, nasopharynx, bladder, or needle probe. The anesthesia provider and circulating nurse can keep a patient warm with other actions such as providing warm fluids through IV or irrigation delivered warm to the scrub person. Recommended fluid temperature is up to 104° F.6 Special fluid warmers are available for long cases; care must be taken to monitor the fluid temperature. Some fluid warmers feature multiple settings and go as high as 110°
F. The patient can sustain burns by hot irrigation fluids. Some nurses have used warm bags of saline placed under the armpits of patients to warm them. This is not a recommended practice because the exact temperature of the bags is unknown and can cause burns. In trauma patients, extreme active warming can be achieved through heated humidified oxygen and anesthesia gases, warm irrigation through peritoneal lavage, dialysis, and heated cardiopulmonary bypass. In the PACU, warm blankets and a forced-air warming gown can accompany the patient from the OR. Most patients transferred to the PACU are normothermic if the recommended guidelines and policies are followed. Every facility should maintain a policy based on EBP, SCIP, AORN, and TJC recommendations.
Hyperglycemia The CDC’s National Diabetes Statistics Report for 2017 indicated that 30.3 million people, or 9.4% of the U.S. population, have diabetes. More than 7.2 million people, or 23.8% of the population, remain undiagnosed.4 Diabetes is a chronic metabolic disease that affects the way the body processes blood glucose. It is classified as hyperglycemia (high blood glucose) related to the defect in the production of insulin (in the case of type 2 diabetes, insulin resistance). According to The Standards of Medical Care in Diabetes 2018, the classic diagnostic criteria are fasting plasma glucose greater than 126 mg/dL, random glucose checks of more than 180 mg/dL, a twohour postprandial glucose tolerance test of equal to or greater than 180 mg/dL, or a hemoglobin A1c greater than 6.5%.7 The categories of diabetes include: type 1, type 2, gestational, and diabetes due to other causes. Type 1 is an autoimmune disease and leads to the destruction of the B-cells and total insulin destruction. Patients must monitor their glucose frequently throughout the day and inject insulin several times a day according to their blood glucose level. Some patients carry a small insulin pump WWW.ORTODAY.COM
IN THE OR
continuing education that delivers basal insulin 24 hours a day when needed with additional shortacting insulin. A small catheter is placed under the skin, which is attached to a pager-sized device. It can be programmed to automatically release insulin into their system. A smart phone application also can alert a patient if glucose numbers are too high or low. The device includes a disconnect port for swimming, showering, or other water-related activities. Type 2 diabetes is the most common type, accounting for 90% to 95% of all cases.7 With type 2, the pancreas makes insulin to move glucose into the cells. The body cannot use the insulin correctly or not enough insulin is produced, causing the glucose to build up in the blood. New studies have revealed that surgery puts stress on the body and causes increased blood glucose levels. Patients without a diabetes diagnosis also may register high glucose levels and require preoperative, intraoperative, and postoperative treatment with insulin. Elevated blood glucose levels are linked to:8 Adverse outcomes SSIs and delayed wound healing Impaired neutrophil function Cellar damage Increased fatty acid production Secretion of hormones (cortisol, glucagon, growth hormone, catecholamine’s) Immune dysfunction Cardiac and vascular dysfunction Patients who underwent general anesthesia for cardiac, general, and abdominal surgery recorded higher postoperative glucose levels. 8 The Society for Ambulatory Anesthesia (SAMBA) and The American Association of Clinical Endocrinologists recommend an intraoperative and postoperative blood glucose level between 140 and 180 mg/dL for at least 24 hours.8 Blood glucose levels can be lowered later based on patient condition and risk of hypoglycemia.
Hypoglycemia Hypoglycemia occurs when the blood WWW.ORTODAY.COM
glucose levels drop to 70 mg/dL or less. Too little food, fasting before surgery, intense exercise, or excess diabetes medication can cause a patient’s blood glucose level to fall. Patients on insulin and oral glucose-lowering drugs can experience hypoglycemia, adverse reactions, injury, accidents, unconsciousness, seizures, brain damage, and death. Injuries and accidents can occur because of confusion, weakness, and motor deficits. Patients become susceptible to falls and loss of consciousness due to low levels of glucose. CMS has made hypoglycemia resulting in death or serious disability while in a health care facility a never event. 4
Signs and Symptoms Glucose is a source of fuel for the human body and a critical element for brain function. The relationship between blood glucose levels and hypoglycemia signs and symptoms vary from person to person and can differ in the same person depending on circumstances. Patients with low blood glucose levels may report mild symptoms, such as sweating, trembling, light-headedness, restlessness, confusion, irritability, and hunger.
Perioperative Management of the Diabetic Patient Guidelines help health care providers prevent hypoglycemia. The guidelines include how to recognize and treat the patient when signs and symptoms become apparent. Blood glucose should be checked according to individualized patient needs when the patient is NPO. Preoperative blood glucose monitoring may prevent adverse surgical outcomes, promote wound healing, and decrease morbidity and mortality. Continuity of regular blood glucose monitoring can help prevent complications. Diabetic patients should receive instruction about when to take insulin or oral medications and how much before a planned surgical procedure. The preoperative nurse should ask if diabetes medication was taken and document the name, amount, and time it was taken.
Also, a blood glucose level should be drawn close to the time of surgery. Postoperative patients with mild hypoglycemic symptoms and blood glucose of less than 70 mg/dL should be treated with a dextrose infusion. This treatment should be repeated until blood glucose is above 70 mg/dL. Studies have shown that surgical patients performed better with fewer complications when intraoperative glucose levels were maintained within 140 to 180 mg/dL. The target glucose level for stable patient’s levels should be less than 140 mg/dL and for critically ill patients less than 180 mg/dL.8 Once surgery is completed and the patient is in PACU, blood glucose levels should be managed between 140 and 180 mg/dL until the patient is stable enough to transition into their presurgical regimen. Goals of 110 to 140 mg/dL may be appropriate for certain patients (if the tighter control does not lead to hypoglycemia). Studies have shown that maintaining blood glucose levels between 80 and 180 mg/dL increases excellent outcomes during the perioperative period and from 140 to 180 mg/ dL during the postoperative period.8 Patients recovering in the PACU who are conscious and can swallow may receive 15 to 20 g of carbohydrates to prevent hypoglycemia. An example would be juice and crackers. The American Diabetes Association (ADA) recommends target premeal blood glucose levels of 90-130 mg/dL and an A1c of less than 6.5%, with more or less stringent goals, depending on the patient. Diabetic patients working with a doctor may have lower target numbers based on age and physical condition.7 Each hospital and outpatient clinic should follow its own hypoglycemic guidelines and policies based on recommendations from recognized organizations and government agencies to improve surgical outcomes.
Hand-Over Communication Improving the effectiveness of communication among caregivers is a common JULY 2020 | OR TODAY |
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IN THE OR
continuing education safety goal. TJC created the Targeted Solutions Tool for Hand-off Communications. It includes using a standardized form, identifying and stressing key information, and conducting the hand-over in a zone of silence.4 A key part of perioperative communication is the hand-over, or a verbal report from one member of the team to another, to ensure continuity of care. To be of value, a hand-over should be accurate and clear. Specific standardized protocols are recommended because the hand-over is associated with communication breakdown and sentinel events.6
Ongoing Communication Hand-over occurs at each stage of the perioperative process, starting with the preoperative area. The preoperative nurse obtains important information from the patient to communicate to the perioperative nurse. This includes identifying the patient using a double identifier of name and birthday or name and medical records number, verifying the consent has been signed, obtaining vital signs, and assessing patient understanding. Other important information is history and physical results, NPO status, medications taken, laboratory test, allergies, and surgical site marking. Before the surgical incision is made, the OR team conducts a Timeout. The Timeout includes verification of correct patient, signed consent, surgical procedure, site marking, NPO status, allergies, antibiotics and other medications given, relevant images, necessary equipment, and implants. Each member plays a vital role by participating in the Timeout process by stopping all activity and listening. All team members must agree with the discussion before incision. Once the surgical procedure is complete, the perioperative nurse communicates with the PACU or ICU nurse by giving a detailed verbal report. Patient identification, history, procedure, medications given, how the procedure was tolerated, fluids given, type of anesthesia, estimated blood loss, oxygen saturation, urine
36 | OR TODAY | JULY 2020
output, complications, hemodynamic stability, dressings, drains, IV placements, and current level of pain are included in the report. The postoperative nurse will receive an estimated time of when the patient will transfer as well as time to gather necessary equipment. A patient should never be transported and left unattended.The postoperative nurse will communicate similar information when the patient transfers to another area. The method of hand-over should be standardized and easy to use. Structured tools can help ensure consistency. One example is the SBAR (Situation, Background, Assessment, Recommendation) format. Another tool is the mnemonic I PASS THE BATON: introduction, patient, assessment, situation, safety concerns, (the) background, actions, timing, ownership, next.6 Hand-over reporting improves when checklists, tools, and protocols are in place. Hand-over communication should occur in a quiet area without distractions. Errors and Sentinel Events occur when information is missing or there is a breakdown in communication. Effective, standardized communication facilitates a safe environment, correct patient information, positive outcomes, and continuity of care. Keeping the patient safe from hypothermia, hypoglycemia, hyperglycemia, and hand-over miscommunication is part of every member of the health care team’s role as a patient advocate. Nurses should ensure their practice is congruent with the latest findings and make practice modifications to keep patients safe.
Surgical Technology Program at Lakeland Community College, Kirtland, Ohio. Anita has co-authored CNOR PASS and contributed to Berry & Kohn’s Operating Room Technique 13th ed. and other publications. She also has authored and contributed to CE articles.
EDITOR’S NOTE: Sophia Mikos-Schild, EdD, MSN, RN, MAM/HROB, CNOR, is the original author of this continuing educational activity but has not had the opportunity to influence this version.
6. AORN. Guidelines for Perioperative Practice.
References 1. Navaratnarajah M, Rea R, Gibson F, et al. Effect of glycaemic control on complications following cardiac surgery: Literature review. J Cardiothorac Surg. 2018;13:10. doi.org/10.1186/ s13019-018-0700-2. 2. Berríos-Torres S, Umscheid C, Bratzler D. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8): 784-791. doi:10.1001/jamasurg.2017.0904. 3. Ban K, Minei J, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2017;224(1):59-74. doi: 10.1016/j.amcollsurg.2016.10.029. 4. 2019 National Patient Safety Goals Presentation. The Joint Commission Web site. https:// jntcm.ae-admin.com/assets/1/6/NPSG_2019_ Presentation_-_FINAL.pdf. Published January 2019. Accessed July 23, 2019. 5. Sun Z, Honar H, Sessler DI, et al. Intraoperative core temperature patterns, transfusion requirement, and hospital duration in patients warmed by forced air. Anesthesiology. 2015;122:276-285. doi: 10.1097/ ALN.0000000000000551.
2018 Edition. Denver, CO. AORN Inc. 7. National diabetes statistics report, 2017. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/diabetes/data/
Relias LLC guarantees this educational activity is free from bias.
statistics-report/index.html. Updated March 6,
Anita M. Hornacky, BS, RN, CST, CNOR, is a perioperative educator for surgical pharmacology and special topics for the
8. Duggan EW, Carlson K, Umpierrez GE.
2018. Accessed July 23, 2019.
Perioperative Hyperglycemia Management: An Update. Anesthesiology. 2017;126(3):547-560. WWW.ORTODAY.COM
Clinical Vignette Karen Summers, 69, is in the preoperative holding area before her scheduled total abdominal hysterectomy. She has type 2 diabetes treated with oral hypoglycemic and regular insulin. She also is connected to an IV. Her vital signs are 132/78 mmHg blood pressure, 37º C temperature, 86 pulse, and 18 respirations. She has eaten nothing by mouth and only taken sips of water to swallow her medications. She appears thin and responds slowly to questions asked. She says she feels “chilly.” Soon, Karen begins to complain of a headache, vertigo, and drowsiness. She becomes pale and struggles to speak. She can state that she did not eat but took her oral medications. The preoperative holding area nurse obtains a blood glucose level per protocol. 1. Considering Karen’s history and planned surgery, the PRIMARY assessment areas for the preoperative holding area nurse include: a. Whether Karen has a family symptoms of hypoglycemia. member with her. c. K aren’s cultural background. b. Temperature and signs and d. K aren’s reflex responses. 2. Karen’s blood glucose level comes back as 40 mg/dL. Which is an appropriate hypoglycemia protocol order? a. Administer 50% dextrose. c. R epeat the blood glucose in b. Administer 15 g of 90 minutes. carbohydrates. d. R epeat the blood glucose in 60 minutes. 3. The preoperative holding area nurse communicates what occurred with Karen to the OR nurse. Which would make the hand-over more effective? a. N ot using the same c. Implementing a standardized hand-over tool for each tool that is easy to use communication d. N ot including time for b. P roviding information that is questions to avoid delays in extremely detailed patient care. 4. In the OR, the nurse will know that Karen is experiencing hypothermia if her temperature is _____ or lower. a. 96.8° F c. 110.4° F b. 98.6° F d. 104° F
Clinical VignettE ANSWERS 1. Answer: B, Hypoglycemic signs and symptoms vary in patients with diabetes and must be monitored closely. Body temperature must be at least 36º C to prevent inadvertent hypothermia. Too little food and/or too much hypoglycemic medication can cause a patient’s blood glucose level to drop below normal. 2. Answer: A, Patients who cannot swallow and have more advanced symptoms (like Karen) typically are treated with 50% dextrose IV. Glucose levels should be retested, according to facility policy after dextrose administration. 3. Answer: C, The hand-over should be standardized and easy to use so it is more effective. A tool can help standardize the hand-over. Handovers should be concise and without interruptions. Questions should be addressed at this time. 4. Answer: A, Unintended hypothermia is the reduction of core body temperature to 96.8° F or lower. Karen is at risk for hypothermia because of anesthesia and the fact that she is undergoing a major surgical procedure. WWW.ORTODAY.COM
CE614
How to Earn Continuing Education Credit 1. Read the Continuing Education article. 2. Go online to ce.nurse.com to take the test for $12. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at https://www.nurse.com/ sign-up for $49.95 per year.
Deadline Courses must be completed by 8/20/2022 3. If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer. 4. Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test. 5. All users must complete the evaluation process to complete course. You will be able to view a certificate on screen and print or save it for your records.
Accredited In support of improving patient care, OnCourse Learning (a Relias LLC company) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider #50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. Relias LLC is approved by the California Board of Registered Nursing, provider # CEP13791.
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UNDERSTAFFING STAFFING
and infections By Don Sadler
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WWW.ORTODAY.COM
T
he Centers for Disease Control and Prevention (CDC) estimate that as many as 1.7 million hospital patients each year acquire an infection while being treated for other conditions. More than 98,000 of these patients die as a result of healthcare associated infections (HAIs) -- or one out of every 17 patients. A substantial body of research over the years has pointed to invasive devices and clinical practice as primary causes of these HAIs. However, some studies indicate another contributing factor to HAIs that can’t be overlooked: nurse understaffing and burnout.
SIGNIFICANT ASSOCIATIONS
A study published in the May 2019 issue of the Journal of Nursing Administration examined whether HAIs and nurse staffing are associated using unit-level staffing data. Patients were tracked throughout their hospital stays and the unit on each day and shift were identified, which allowed direct measure of each patient’s exposure to staffing levels. The study found significant associations between HAIs and nurse understaffing. The risk of HAIs at any given time in patients on units with nurse understaffing on both day and night shifts two days prior to infection onset was 15% higher than for patients in units staffed at or above 80% of the unit median. In addition, the risk of HAIs in patients on units with nurse understaffing on both day and night shifts two days prior to infection onset was 11% higher than for patients in units that were adequately staffed. “There’s definitely a lot of validity to this study,” says Peter F. Nichol, MD/PhD, associate professor of surgery
in the Division of Pediatric Surgery at the University of Wisconsin SMPH. “It lines up with my personal observation that nurse shortages have a significant impact on HAIs and surgical site infections (SSIs) in patients coming out of the OR and on the floor.” “Understaffing puts an enormous amount of pressure on nurses and creates an unsafe environment for both patients and these essential providers,” adds Hilary Babcock, MD, MPH, past president of the Society for Healthcare Epidemiology of America (SHEA).
MORE STUDY RESULTS
Another study published in the American Journal of Infection Control had similar findings. This study found a significant association between patient-nurse staffing and both urinary tract infections (UTIs) and SSIs. Overall, 16 patients out of every 1,000 acquired some type of infection while hospitalized. UTIs were the most common (8.6 per 1,000 patients), followed by SSIs (4.2 per 1,000 patients) and gastrointestinal infections (2.5 per 1,000 patients). The study found a significant association between staffing and UTIs, where each additional patient assigned to a nurse was associated with an increase of nearly one infection per 1,000 patients. A similar finding was reported for SSIs. In the study population, this would translate to about 1,350 additional infections for each patient added to a nurse’s workload. “Our study and other research make it clear that as you increase the number of patients – HILARY BABCOCK, MD, MPH, nurses have to care for, more patients are at risk PAST PRESIDENT OF THE SOCIETY FOR HEALTHCARE EPIDEMIOLOGY OF AMERICA (SHEA) for infection and infection-related outcomes
"
Understaffing puts an enormous amount of pressure on nurses and creates an unsafe environment for both patients and these essential providers.
WWW.ORTODAY.COM
"
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JEANNIE P. CIMIOTTI PHD, RN, FAAN
such as morbidity and mortality,” says study co-author Jeannie P. Cimiotti, PhD, RN, FAAN, associate professor at the Nell Hodgson Woodruff School of Nursing at Emory University.
THE IMPACT OF BURNOUT
In addition to staffing shortages, Cimiotti and her team also measured the impact of nurse burnout on patient infections. More than one-third of all nurses in the study reported high levels of job burnout and this burnout was highly associated with both UTIs and SSIs. “In other words, a 10% increase in a hospital’s composition of high-burnout nurses is associated with an increase of nearly one UTI and two SSIs per 1,000 patients,” Cimiotti explains. “So burnout contributes even more to increased patient infection rates than understaffing. This makes sense because increased workloads result in more burnout – it’s difficult to separate the two.” Importantly, the researchers found that lowering nurse burnout reduces infection rates and the associated costs of infection across the range of burnout levels. “This is most pronounced when burnout is reduced by 30 percent,” says Cimiotti. When this occurs, UTIs can be reduced by more than 4,000 infections and SSIs by more than 2,200 infections, the study found. This translates to annual hospital cost savings of between $28 million and $69 million. “The takeaway is clear: Differences in nurse workloads across hospitals are strongly associated with transmission of infections,” says Cimiotti.
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HILARY BABCOCK MD, MPH
A MULTI-FACTORIAL PROBLEM
Both Nichol and Cimiotti acknowledge that HAIs are a multi-factorial problem with many different potential causes. “Hospitals have done a number of things the past few years to try to drive down the rates of infection, but we’ve also seen high rates of nurse turnover,” says Nichol. Of course, the nursing shortage has been well-publicized for years. According to the American Association of Colleges of Nursing, the number of nurses leaving the field each year has doubled over the past decade -- from around 40,000 in 2010 to a projected 80,000 this year. With more than half of nurses now 50 years of age or over, it’s projected that one million nurses will retire over the next decade. The Bureau of Labor Statistics projects the need for an additional 203,700 new nurses each year through 2026 to fill newly created positions and replace these retiring nurses. Given these statistics, the solution to remaining fully staffed and helping nurses avoid burnout in order to reduce HAIs lies in creating a culture where nurses are appreciated, says Nichol. “Many hospitals tend to pay lip service to this,” he says. “There’s no question that we need to double down when it comes to making sure nurses feel valued.” Nichol recommends that hospitals “flatten the hierarchy” so nurses have more input when it comes to policies and procedures that affect the way they do their jobs. “With a vertical hierarchy it’s hard for those who see what needs to be done to get their voice heard and help bring about change.”
PETER F. NICHOL MD, PHD
“The charge nurse who runs the OR is just as important as the surgeon because he or she has to coordinate and keep everything running smoothly,” Nichol adds. “But the charge nurse usually doesn’t have a seat at the decisionmaking table.” Cimiotti concurs. “It’s important to create a climate where everyone is respected. Unfortunately, we don’t see this in every hospital, which is disappointing to say the least,” Cimiotti says. “It doesn’t cost anything to create an environment where everyone’s input and opinion is valued.”
PATIENT MONITORING INNOVATIONS
Babcock says recent innovations that have improved patient monitoring can also help. “Infection prevention and control training is a critical part of the solution,” she says. “Training provides frontline personnel with the information and skills they need to successfully apply best practices for safe care.” “As the research has shown, when frontline providers have the resources they need, there are measurable improvements in the prevention of HAIs,” Babcock adds. SHEA has released a new online training program, Prevention Course in Healthcare-Associated Infection Knowledge and Control (https://bit. ly/36Qd6rw). “This course is designed to train frontline health care personnel in best practices to prevent and control HAIs and pathogens that can spread in the health care setting,” says Babcock. WWW.ORTODAY.COM
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S P O T L I G H T
O N :
RN B S N
Hannah By M at t S ko u fa l o s
W
Miller
hen Hannah Miller began studying for a career in health care at the University of CaliforniaSanta Cruz, she didn’t anticipate that career would be nursing. Miller, who’s about two years into her professional life as a staff and charge nurse at Good Samaritan Hospital in San Jose, California, initially pursued a degree in molecular, cellular and developmental biology.
“I was teetering back and forth as to which path in the health care field was best for me,” she said. “The focus on health education and preventive care that nurses have drew me toward that field.” Miller pushed through an accelerated degree program, and not long after, found herself in the orthopedic setting. She hadn’t planned on that specialty, but
quickly fell in love with orthopedic care, in large part due to the opportunity to educate her patients prior to and after their surgeries. Good Samaritan performs a number of joint replacements, and she appreciates its “really smooth flow” from start to finish. Most patients are discharged within a day or two after their procedures. “Ortho was the job that I was offered, but I ended up loving it more than I expected to,” Miller said. “I love surgery a lot because it’s a very streamlined process. There’s a lot of education that goes along with that. The nurse is there to explain what happened in surgery; how we’re going to get them home and back to their regular lives.” “I like the consistency of the patient population and how positive and encouraging my work environment is,” she said.
“Within four hours, patients have to ambulate for the first time. Having them take their first steps is always a really exciting moment for me," she added. Although she wasn’t sure for how long she’d keep that assignment, Miller’s fledgling career was turned completely upside-down in March 2020, when the orthopedic unit closed in the midst of the novel coronavirus (COVID-19) pandemic. Elective surgeries were postponed, and staff who weren’t required to report to work were offered 30-percent pay cuts rather than layoffs or using paid time off. Miller made herself available
Hannah Mill er donned PPE to
provide ca re to COVID 19 patients.
to work in the COVID unit when the need arose. “It’s been kind of crazy,” she said. “My unit shut down completely in early to mid-March. They opened up one of the floors as a COVID unit, so I was just floating to that and a couple of other units as needed. It was totally out of the context of my normal job.” Miller said she faced a steep learning curve – different skills are required in a respiratory unit than in an orthopedic setting – and she was grateful for the support of her coworkers. “It always makes it so much better when you have people supporting you and helping,” Miller said. “I didn’t have any issues being on the COVID floor; I was happy to be available to help these patients. Yes, we are putting ourselves at risk, but we treat patients with infectious diseases all the time. It’s a part of the job that I’m happy to take
care of these patients.” For health care workers, as much as anyone else picking their way through the pandemic, the biggest difficulty Miller said she felt was “the information wars.” With constantly shifting policies amid a rapidly evolving (and occasionally conflicting) governmental response, “it was really stressful for me to not know what’s coming,” she said. “We had to play it by ear,” Miller said. The San Francisco Bay Area was locked down earlier than most parts of the country, and by doing so, managed to suppress its COVID-19 cases. The only patients still in Miller’s unit at Good Samaritan are the ones who are the sickest; some have been in a hospital for a month or longer. Although she hasn’t had any patients intubated or die on her watch, those who are under her care “are really sick,” Miller said. “The hardest part is how alone and really isolated they are,” she said. “Patients are in physical isolation, and we don’t allow visitors. There is a very limited number of health care staff allowed to enter the room, so many times nurses are the only ones there.” Those conditions put a priority on her bedside manner. Miller’s roles largely include handholding, counseling family members, and trying to mitigate the stress of missing loved ones. She emphasized the support of her colleagues in helping “hold us all together.” When she’s not working, Miller
d r, Eli, an brothe ith her w n e . e s ht) Miller is iend, Jon (rig Hannah boyfr
spends time with family and enjoys reading, writing, dining out and being outdoors. Her brother recently moved in because the pandemic struck while he was attending college, and the two are bonding “more than ever before,” she said. As her career continues to flourish, Miller says she could see expansive opportunities in the nursing field in any variety of care settings. Eventually, she may move on from a bedside care environment, and can see herself pursuing leadership or educational roles. “What I’m trying to do is figure out what I’m really good at, what do I enjoy doing, and trying to find my niché,” Miller said. “Teaching is something I want to be a big part of my career at some point. I’m also the go-to person when there’s technological issues on the unit, so I could see health care tech being a part of my future as well.” Part of that future could well include the operating or recovery room, Miller said, although she foresees developing different skills in an environment where patients are “almost always asleep.” “One of the most rewarding things about nursing is getting to be a patient advocate,” she said; “noticing something at the bedside that’s not right, that saves someone’s life, or that prevents a bad outcome. Just knowing that you did something, that you were there to intervene, is important.” JULY 2020 | OR TODAY |
43
OUT OF THE OR fitness
The Power Behind HIIT
By Miguel J. Ortiz igh Intensity Interval Training (HIIT) has been used worldwide by professional athletes and coaches to help clients achieve anything from their general athletic aspirations to improving speed and agility. The types of circuits and different intervals I have seen from coaches is very impressive. Some of the movements can tend to be pretty demanding. So, does that mean you have to do the hardest movements or really drive your heart rate out the roof? Absolutely not!
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With power comes control, and when doing HIIT it's important to understand that it’s not about how hard you go or how difficult the exercise, it’s about how consistently well you preform the exercise under control so that you have the best efficiency. Follow these three tips when utilizing HIIT in a program. First, we must ensure that our body, as well as our heart rate, is capable of performing these movements. By definition of “High Intensity,” a quality HIIT workout will get one’s heart rate
44 | OR TODAY | JULY 2020
to about 80% of its maximum capacity. So, if you haven’t pushed yourself in quite some time, a good interval to try could be a 4 by 4. Perform a 5-10 minute warm-up, do four intervals of a high intensity run followed by four intervals of a slow walk. Then, do a five-minute cool down to relax. HIIT workouts are short, never lasting longer than 30 minutes including the warm-up and cool down periods. However, they will also challenge one’s heart rate. Individuals will have time to recover, but it will be brief. Second, when utilizing HIIT workouts in a program one should keep in mind that they don’t all have to be cardio-based exercises. Individuals can throw in some strength work – which is another reason why HIIT workouts continue to gain popularity. Just remember to push the heart rate to a good 80%, keep the workload and recovery short and sweet. Knock out a couple of intervals and the result is a solid workout. When considering strength work, try some total body movements to ensure the heart rate still gets up. Try this HIIT workout (kettle bell required), 40 seconds of work followed by 20 seconds of rest. So, every minute on the
minute you’re doing work, aka, EMOM, 3 rounds is 9 minutes. HIIT Workout Kettle bell swings Push up to high knee Kettle bell goblet squat Finally, interval training is hands down one of the best ways to strengthen your heart, as the cardio-respiratory benefits are incredible for weight loss and improving your VO2 max. Which is how efficient the body takes in and utilizes oxygen. With that being said, I see a lot of people doing proper intervals and exercises however the recovery needed outside of the workout must increase. The reason for this is because your body is being pushed pretty hard. It may only be for a short period of time, but the demanding movements require proper self-care. So, plan extra recovery and stretching. Have fun with your HIIT workouts. Miguel J. Ortiz is a personal trainer in Atlanta, Georgia. He is a member of the National Personal Trainer Institute and a Certified Nutritional Consultant with more than a decade of professional experience. He can be found on Instagram at @migueljortiz. WWW.ORTODAY.COM
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I HAVE ALWAYS BEEN CREATIVE AND LOVE FIXING THINGS. AS I HAVE AGED, MY CREATIVE FOCUS HAS SHIFTED TO MAKING A DIFFERENCE AND HELPING THOSE WHO CANNOT ALWAYS HELP THEMSELVES. IT HAS MANIFESTED INTO A THREE-DECADE CAREER IN HEALTHCARE WHERE I HAVE BEEN ABLE TO IMPROVE QUALITY AND EFFICIENCY REGARDING PATIENT CARE. – Brian Arndt
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Brian is a speaker at OR Today Live! To learn more, visit www.ortodaylive.com.
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OUT OF THE OR health
Diet May Help Preserve Cognitive Function ccording to a recent analysis of data from two major eye disease studies, adherence to the Mediterranean diet – high in vegetables, whole grains, fish, and olive oil – correlates with higher cognitive function. Dietary factors also seem to play a role in slowing cognitive decline. Researchers at the National Eye Institute (NEI), part of the National Institutes of Health, led the analysis of data from the Age-Related Eye Disease Study (AREDS) and AREDS2. They published their results in the journal Alzheimer’s and Dementia.
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“We do not always pay attention to our diets. We need to explore how nutrition affects the brain and the eye” said Emily Chew, M.D., director of the NEI Division of Epidemiology and Clinical Applications and lead author of the studies. The researchers examined the effects of nine components of the Mediterranean diet on cognition. The diet emphasizes consumption of whole fruits, vegetables, whole grains, nuts, legumes, fish, and olive oil, as well as reduced consumption of red meat and alcohol. AREDS and AREDS2 assessed over years the effect of vitamins on agerelated macular degeneration (AMD), which damages the light-sensitive retina. AREDS included about 4,000 WWW.ORTODAY.COM
participants with and without AMD, and AREDS2 included about 4,000 participants with AMD. The researchers assessed AREDS and AREDS2 participants for diet at the start of the studies. The AREDS study tested participants’ cognitive function at five years, while AREDS2 tested cognitive function in participants at baseline and again two, four and 10 years later. The researchers used standardized tests based on the Modified Mini-Mental State Examination to evaluate cognitive function as well as other tests. They assessed diet with a questionnaire that asked participants their average consumption of each Mediterranean diet component over the previous year. Participants with the greatest adherence to the Mediterranean diet had the lowest risk of cognitive impairment. High fish and vegetable consumption appeared to have the greatest protective effect. At 10 years, AREDS2 participants with the highest fish consumption had the slowest rate of cognitive decline. The numerical differences in cognitive function scores between participants with the highest versus lowest adherence to a Mediterranean diet were relatively small, meaning that individuals likely won’t see a difference in daily function. But at a population level, the effects clearly show that cognition and neural health depend on diet. The researchers also found that par-
ticipants with the ApoE gene, which puts them at high risk for Alzheimer’s disease, on average had lower cognitive function scores and greater decline than those without the gene. The benefits of close adherence to a Mediterranean diet were similar for people with and without the ApoE gene, meaning that the effects of diet on cognition are independent of genetic risk for Alzheimer’s disease. The AREDS and AREDS2 studies were supported by the NEI Intramural Research Program and contracts NOI-EY-0-2127 (AREDS), HHS-N260-2005-00007-C (AREDS2), and N01-EY-5-0007 (AREDS2). Additional research funds were provided by the NIH Office of Dietary Supplements, the National Center for Complementary and Integrative Health, the National Institute on Aging, the National Heart, Lung, and Blood Institute, and the National Institute of Neurological Disorders and Stroke. The AREDS trial is registered at www.ClinicalTrials.gov as NCT00594672. AREDS2 is registered as NCT00345176. The studies took place at the NIH Clinical Center.
Reference Keenan TD, Agron E, Mares J, Clemons TE, van Asten F, Swaroop A, and Chew E, for the AREDS and AREDS2 research groups. “Adherence to a Mediterranean diet and cognitive function in the Age-Related Eye Disease Studies 1 & 2.” April 14, 2020. Alzheimer’s and Dementia. JULY 2020 | OR TODAY |
47
OUT OF THE OR EQ factor
The Impact of Harmony vs. Practicality By daniel bobinski id you know that people can be motivated – or demotivated – simply by their surroundings?
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This article is the third in a series about the six learned (extrinsic) motivators. In the first installment, I examined the different ways people are motivated by knowledge. Last month, we looked at how tangible things – including money – may or may not motivate us. In this third installment, we’ll look at the different ways we are driven by our surroundings.
The motivational spectrum of surroundings At one end of the surroundings scale are people we call harmonious. They’re driven to succeed in environments that have balance, whether it is aesthetic, relational, or both, and they thrive when they can create or work in harmonious environments. At the other end of the scale are people more concerned about functionality. People scoring strongly here are called objective, and their productivity is enhanced when they can arrange their environment in the most practical way possible. All people value their surroundings, they just value surroundings in different ways.
Traits of a harmonious person People favoring the harmonious end of
48 | OR TODAY | JULY 2020
the surroundings spectrum value and enjoy beauty and balance, and they derive fulfillment when they can create or enjoy harmony in their environment and their relationships. Consider a woman who worked in a call center who was considered an average performer. When a cubical became available near a window, she requested it. Her supervisor was hesitant, fearing the woman would stare out the window and daydream, causing her to become less productive. But another supervisor, one familiar with motivational styles, recommended the move, so the woman was given the cubical on a trial basis. Three months later, energized by being able to look out at the trees and squirrels and birds while she worked, the woman’s productivity had increased by 30 percent.
Traits of an objective person People on the objective side of the surroundings spectrum are not distracted by a lack of balance, focusing instead on practicality and functionality of what’s around them. Environments that might seem chaotic to some are of no concern to an objective person, so long as a desired outcome can be achieved. In fact, if harmony supersedes functionality, productivity can suffer. Consider a short-order cook who arranged his cooking utensils functionally, according to how often he used them. When the restaurant hired an-
other cook, one with a strong harmonious score, the new cook rearranged all the pots, pans and utensils so they were visually balanced. The next day, when the first cook came in, he found the new arrangement impractical. The differences on this motivational scale can be problematic when an organization implements Six Sigma, the data-driven standardization approach for eliminating defects and gaining optimal continuous improvement. When personalization is removed from a workplace, the goal of performance improvement may actually backfire, diminishing the productivity of those with strong harmonious drivers. By way of reminder, it’s easy to say one motivator is bad while another is good. I always urge people to value the differences rather than criticize them. 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 Daniel through his website, MyWorkplaceExcellence.com, or his office: (208) 375-7606.
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JULY 2020 | OR TODAY |
49
OUT OF THE OR nutrition
Another Win for the Mediterranean Diet By Charlyn Fargo
ere’s yet another reason to try the Mediterranean diet, which is actually not a strict diet at all but a pattern of eating that focuses on fresh, whole foods and avoids highly processed foods.
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New research finds it may support healthy aging. And who among us doesn’t want to live a long, healthy life? Research published in The BMJ in February 2020 found that the Mediterranean lifestyle helps alter gut bacteria, which, in turn, helps reduce frailty and promote healthy aging. The gut microbiota of more than 600 people in five European countries were profiled before they began a one-year-long Mediterranean diet. When their gut bacteria were checked at the end of the year, they had better bacterial diversity in the gut, and the bacteria that increased in volume were associated with reduced frailty (improved walking speed, hand strength and cognitive function, and less inflammation). Just what is a Mediterranean diet? It is based on the dietary habits of people in Italy and Greece. Much of the diet consists of vegetables, fruits, whole grains, beans, herbs, nuts, seafood and olive oil. Poultry, eggs, cheese and red wine are consumed in moderation. Red meat, refined grains, processed foods and sugar-sweetened beverages are only
50 | OR TODAY | JULY 2020
consumed in small amounts. How can you get started? Start the day with a bowl of oatmeal with fresh berries. Have some tuna over a leafy green salad for lunch and a piece of salmon over brown rice with vegetables for dinner. Enjoy a glass of red wine with dinner, too. Think fresh, whole foods. As you age, you’ll be happy you did.
Healthy Lifestyle, Longer Life It’s always a great time to make a new start on your healthy lifestyle. For years, doctors have advocated a healthy diet, regular exercise, stress relief and weight control. A recent study confirms there are tangible benefits. A Dutch study finds that the presence of all these healthy lifestyle factors was associated with two extra years of good health compared with those highrisk lifestyles. Another study found that those without any lifestyle risk factors lived, on average, six years more without chronic disease compared with those who had two or more risk factors. And in case you’re still not convinced, a third study showed that without any risk factors, people lived, on average, nine years longer before the onset of any chronic disease. Find time to take a daily walk or do an online workout video, cook a homemade meal (with plenty of vegetables, fruit and whole grains) and get a little
extra sleep. What most of us seem to lack isn’t really the time (like we profess) but the desire to improve our habits. That’s why I highlighted these studies this week. The choices you are making now toward a healthier lifestyle really do make a difference down the road. Just what combination of healthy lifestyle factors is needed? A new study, published this month in JAMA Internal Medicine, answers that question. The researchers designed a prospective study comprising over 116,000 people from 1991 to 2006 and included 12 European studies. Participants were scored on each of four lifestyle factors, including smoking, body mass index, physical activity and drinking. They found healthy body weight essential to a healthy lifestyle profile, along with physical exercise, absence of smoking and less than one drink a day for women and two for men. The end result? Ten more years of healthy life in men and 9.4 more in women, compared with men and women with the lowest lifestyle scores. Charlyn Fargo is a registered dietitian at Hy-Vee in Springfield, Illinois, and the media representative for the Illinois Academy of Nutrition and Dietetics. For comments or questions, contact her at charfarg@aol. com or follow her on Twitter @NutritionRD. WWW.ORTODAY.COM
Recipe the
OUT OF THE OR recipe
Build Simple Breakfasts to
Fuel Your Family
5 TIPS TO START YOUR DAY WITH NUTRITIOUS NOSHES BY Family Features ating healthier is always a popular goal. One of the many aspects to focusing on better nutrition starts with a better breakfast.
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To help boost you and your family’s immunity, try focusing on protein- and fiber-packed morning meals that are low in sugar. That doesn’t have to mean hours of prep in the kitchen or stocking up on uncommon ingredients. Instead, you can start with simple recipes that call for just a handful of inclusions. Additionally, when your menu is centered around less complicated dishes, it allows an opportunity to get kids involved in the kitchen with tasks like measuring yogurt for a parfait, pouring milk in a pudding recipe or simply pulling ingredients out of the pantry and refrigerator. To help start your healthy breakfast plan on the right foot, consider these tips from Dr. Jonathan Clinthorne and the experts at SimplyProtein:
Factor in fiber. When it comes to supporting immunity with nutrition, one of the underappreciated nutrients is dietary fiber. Fiber feeds gut bacteria, which helps produce numerous compounds that accelerate the development of immune cells and boost their function. The immune system performs better when people replace highly refined, lowfiber carbohydrates with fiber-rich carbohydrates.
Pick ingredients packed with protein. It’s important to consume adequate protein when looking to boost WWW.ORTODAY.COM
immune function as protein energy malnutrition is linked to poor immune function and can impair the ability of the immune system to fight viruses and bacteria. Add foods to your diet like SimplyProtein’s line of non-GMO, gluten-free bars and bites. The snacks include 11 or more grams of protein and just 0-3 grams of sugar without artificial sweeteners, artificial flavors or artificial preservatives for nutritious treats to help make busy lives simpler.
Build a balanced breakfast. People burn more energy through a process known as “diet-induced thermogenesis” when they consume high-calorie breakfasts rather than high-calorie dinners. This can ultimately help with weight loss and suggests that eating more food early in the day is better for you than eating a large amount before bedtime. For example, this recipe for Yogurt Parfait provides protein and energy with simple at-home prep.
INGREDIENTS: • 1 cup Greek vanilla yogurt • 1/2 cup assorted fruit, such as strawberries, blueberries and kiwi • 1 tablespoon shaved almonds • 1 SimplyProtein Chocolate Chip Cookie Bar, crumbled • shaved coconut (optional)
Skip the sugar. Avoid the post-lunch sleepy feeling by ditching sugar. Instead, focus on low-glycemic snacks that won’t spike blood sugar, helping to control your appetite.
Feel fuller longer. Eating immune supportive foods like vegetables, berries, nuts, seeds and protein-rich snack bars can help keep you full and satisfied while avoiding less nutritious alternatives. Find more protein-packed solutions at simplyprotein.com.
Yogurt Parfait
In bowl, layer yogurt, fruit and shaved almonds. Top with crumbled cookie bar and shaved coconut, if desired.
JULY 2020 | OR TODAY |
51
OUT OF THE OR pinboard
CHE C K O U T O U R N E W CO NTEST!
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YEAR OF THE NURSE OR Today magazine 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 wants to feature nurses in a new contest! Every entry wins a gift card! To enter the contest, share a time when a nurse served as an inspiration to you or your team. This can be a peer, a mentor, an educator or anyone from the nursing profession. Help us shine a spotlight on these individuals. Please share your brief (1 to 3 sentences) contest entry at ORToday.com/Contest. One gift card per individual.
H QUOTE OF THE MONT
orrow.” m to in e v e li e b to is “To plant a garden rn – Audrey Hepbu
52 | OR TODAY | JULY 2020
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The News and Photos
that Caught Our Eye This Month
OUT OF THE OR pinboard
AT-HOME SUMMER LEARNING TIPS
M
any parents are feeling the stress of taking more active roles in their children’s education. As time away from the classroom extends into summer, parents also face the challenge of helping their children maintain what they’ve learned through a summer of uncertainty.
reading together or talking about baseball statistics – can have a greater impact on their children’s academic performance than popular summer activities, such as summer camps, travel or summer school. This year’s shift to at-home learning has provided plenSince education can happen anywhere as part of ty of resources parents can use to keep their children’s everyday life, there are many activities families can do minds engaged and actively learning. The shift has also together to create a sense of summertime fun while prompted families to create new routines and healthy fostering academic growth. learning habits. Continuing these best practices over • Spend some time cooking or baking together. the summer may prove beneficial in setting students Use these experiences as opportunities to practice up for success when they return to the classroom. reading recipes or practice math by measuring •S et a clear daily schedule with realistic goals and and adding ingredients. be sure to allow flexibility. A child’s attention span •W ork with other parents or family members to grows longer with age – typically 2-3 minutes per find summer pen pals. Have kids write letters back year of age – so the amount of time an elementary and forth to practice reading and writing skills. school student will focus on a task may be signifi•E xtend story time with read-and-do activities cantly shorter than a high school student. that lay the groundwork for developing engaged •B uild in time for kids to play. According to the readers. For example, the Pizza Hut BOOK IT! Projournal, Pediatrics, playing promotes healthy brain gram offers free online activities at bookitprogram. development and boosts academic skills. Play time com children and parents can do together, such as also helps children manage stress – making it an drawing, letter recognition or sight-word bingo. important and fun way for parents to support kids • Explore science and nature by taking a walk. Try coping with stress or anxiety. and identify different types of clouds, trees, plants, •C reate a conducive learning environment at rocks and animals. Take pictures of any you find home. If possible, set up a designated desk and interesting. Then look up additional information distraction-free workspace children can use for when you return home to practice research skills. everything from completing school assignments • Watch the news or read about current events to playing educational games. together. This can provide practical lessons on While routines are important, they may not be the social studies and help kids raise questions about only key to summer learning success. Research from the world around them. Harvard indicates parents who engage with their children in simple activities over the summer – like – Family Features
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JULY 2020 | OR TODAY |
53
INDEX
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ALPHABETICAL Action Products, Inc.……………………………………… 25
Encompass Group………………………………………………13
MedWrench……………………………………………………… 46
AIV Inc.…………………………………………………………………17
Healthmark Industries Company, Inc.…………… 5
OR Today Webinars………………………………………… 22
Alco Sales & Service Co.………………………………… 45
Innovatus Imaging……………………………………………… 6
Ruhof Corporation…………………………………………… 2-3
Augustine Surgical Inc.…………………………………… 26
Jac-Cell Medical…………………………………………………41
Soma Technology………………………………………………19
C Change Surgical……………………………………………IBC
Jet Medical Electronics Inc…………………………… 25
TBJ Incorporated……………………………………………… BC
Cygnus Medical…………………………………………………… 9
MD Technologies Inc.……………………………………… 49
Doctors Depot…………………………………………………… 4
Medeon…………………………………………………………………18
CATEGORICAL ANESTHESIA
Healthmark Industries Company, Inc.…………… 5
Ruhof Corporation…………………………………………… 2-3
Augustine Surgical Inc.…………………………………… 26
MD Technologies Inc.……………………………………… 49
TBJ Incorporated……………………………………………… BC
Doctors Depot…………………………………………………… 4
Ruhof Corporation…………………………………………… 2-3
Soma Technology………………………………………………19
TBJ Incorporated……………………………………………… BC
RESPIRATORY
C-ARM
INSTRUMENT STORAGE/TRANSPORT
Soma Technology………………………………………………19
Cygnus Medical…………………………………………………… 9
CARDIAC PRODUCTS
Ruhof Corporation…………………………………………… 2-3
C Change Surgical……………………………………………IBC
LAPAROSCOPY
Jet Medical Electronics Inc…………………………… 25
Jac-Cell Medical…………………………………………………41
CARTS/CABINETS
Medeon…………………………………………………………………18
Soma Technology………………………………………………19
SAFETY Healthmark Industries Company, Inc.…………… 5
SINKS Ruhof Corporation…………………………………………… 2-3 TBJ Incorporated……………………………………………… BC
STERILIZATION
ALCO Sales & Service Co.……………………………… 45
MONITORS
Cygnus Medical…………………………………………………… 9
Doctors Depot…………………………………………………… 4
Healthmark Industries Company, Inc.…………… 5
Soma Technology………………………………………………19
TBJ Incorporated……………………………………………… BC
MRI
CS/SPD
Innovatus Imaging……………………………………………… 6
MD Technologies Inc.……………………………………… 49
ONLINE RESOURCE
Ruhof Corporation…………………………………………… 2-3
MedWrench……………………………………………………… 46
Medeon…………………………………………………………………18
DISINFECTION
OR Today Webinars………………………………………… 22
Soma Technology………………………………………………19
Cygnus Medical…………………………………………………… 9
OR TABLES/BOOMS/ACCESSORIES
Ruhof Corporation…………………………………………… 2-3
SURGICAL INSTRUMENT/ACCESSORIES
Action Products, Inc.……………………………………… 25
C Change Surgical……………………………………………IBC
DISPOSABLES
Soma Technology………………………………………………19
Cygnus Medical…………………………………………………… 9
ALCO Sales & Service Co.……………………………… 45
OTHER
Healthmark Industries Company, Inc.…………… 5
ENDOSCOPY
AIV Inc.…………………………………………………………………17
TELEMETRY
Cygnus Medical…………………………………………………… 9
PATIENT MONITORING
AIV Inc.…………………………………………………………………17
Healthmark Industries Company, Inc.…………… 5
AIV Inc.…………………………………………………………………17
MD Technologies Inc.……………………………………… 49
TEMPERATURE MANAGEMENT
Jet Medical Electronics Inc…………………………… 25
Augustine Surgical Inc.…………………………………… 26
Ruhof Corporation…………………………………………… 2-3
PATIENT WARMING
C Change Surgical……………………………………………IBC
FALL PREVENTION ALCO Sales & Service Co.……………………………… 45 Encompass Group………………………………………………13
FLUID MANAGEMENT MD Technologies Inc.……………………………………… 49
GENERAL AIV Inc.…………………………………………………………………17
HOSPITAL BEDS/PARTS
Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…………… 5 MD Technologies Inc.……………………………………… 49 TBJ Incorporated……………………………………………… BC
SURGICAL MD Technologies Inc.……………………………………… 49
Encompass Group………………………………………………13
Encompass Group………………………………………………13
POSITIONING PRODUCTS
TEST EQUIPMENT
Action Products, Inc.……………………………………… 25
Jac-Cell Medical…………………………………………………41
Cygnus Medical…………………………………………………… 9
ULTRASOUND
PRESSURE ULCER MANAGEMENT
Innovatus Imaging……………………………………………… 6
Action Products, Inc.……………………………………… 25
WASTE MANAGEMENT
REPAIR SERVICES
MD Technologies Inc.……………………………………… 49
Cygnus Medical…………………………………………………… 9
TBJ Incorporated……………………………………………… BC
ALCO Sales & Service Co.……………………………… 45
Doctors Depot…………………………………………………… 4
WOUND MANAGEMENT
INFECTION CONTROL
Jet Medical Electronics Inc…………………………… 25
Medeon…………………………………………………………………18
ALCO Sales & Service Co.……………………………… 45
Soma Technology………………………………………………19
Cygnus Medical…………………………………………………… 9
REPROCESSING STATIONS
Encompass Group………………………………………………13
MD Technologies Inc.……………………………………… 49
54 | OR TODAY | JULY 2020
X-RAY Innovatus Imaging……………………………………………… 6
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WE ONLY MAKE ONE SINK… THE BEST ONE FOR YOU DESIGNED BY YOU!
TBJ’s SurgiSonic® 1211X features a patented dual hook up method for pre-cleaning da Vinci® instruments utilizing a filtered, independent flushing system combined with ultrasonic action. The unit is independently tested for cleaning effectiveness and exceeded AAMI TIR 30. Three instruments can be pre-cleaned simultaneously.
TBJ sinks are designed specifically for the pre-cleaning of surgical instruments and endoscopes. All of our sinks are custom made to order to enable you to design a system around your specific needs. A wide range of optional features and accessories enable you to tailor a design that puts the tools you for efficient, effective and ergonomic pre-cleaning right at your fingertips.
The system is also ideal for other types of non-robotic submersible tubular instruments as six instruments can be pre-cleaned simultaneously. Available in an economical counter top unit or floor standing unit with automatic water filling and automatic drain control.
OPTIONAL FEATURES INCLUDE Integrated Ultrasonic System
Air and water pistols
Auto Fill System
Automated Lumen and Scope Flushing
Additional Options not shown: Push-button Height Adjustment - Auto sink bowl filling | Heated Sink Bowls | Custom Sink Bowl sizes | DI/RO faucets | Integrated Sonic Irrigator | Etched sink gallon markings | Storage shelves and drawers | Deck mounted Eyewash | Stainless steel peg board storage system
717.261.9700 sales@tbjinc.com www.tbjinc.com
