OR Today Magazine December 2020 by MD Publishing

PRODUCT FOCUS STERILIZATION

CE ARTICLE MECHANICAL VENTILATION AND WEANING

SPOTLIGHT PROFILE LISA VANDEER, RN, CNOR

LIFE IN AND OUT OF THE OR

FITNESS STRONG LEGS

DECEMBER 2020

Y E A R

O F

T H E

NURSE & MIDWIFE PAGE 42

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OR TODAY | December 2020

contents features

YEAR OF THE NURSE & MIDWIFE OR Today joins The World Health Organization in celebrating “The Year of the Nurse and the Midwife.” This year was chosen to recognize the 200th anniversary of the birth of Florence Nightingale.

A MarketsandMarkets press release states that the sterilization equipment market is projected to reach $13.6 billion by 2025.

The goal of this continuing education program is to provide nurses with a more in-depth understanding of mechanical ventilation and the weaning process for critically ill patients.

One of the more damaging choices we can make is resentment. Simmering with jealousy creates barriers that inhibit teamwork and productivity.

GLOBAL STERILIZATION SERVICES MARKET WORTH BILLIONS

MECHANICAL VENTILATION AND WEANING

HOW TO DO AWAY WITH RESENTMENT

OR Today (Vol. 20, Issue #12) December 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 8 News & Notes 18 IAHCSMM: Key Updates to AORNâ&#x20AC;&#x2122;s Guideline for Care and Cleaning of Surgical Instruments 20 Surgery Starts Here: One Giant Leap for Infection Prevention 22 ASCA: Three Studies Demonstrate Value ASCs Deliver to Public, Private Insurers 24 CCI: Recruitment and Retention in the Surgical Suite 26 Webinars Address Hot Topics

CIRCULATION Lisa Lisle Jennifer Godwin

ACCOUNTING Diane Costea

EDITORIAL BOARD Hank Balch, President & Founder, Beyond Clean

IN THE OR 28 M arket Analysis: Global Sterilization Services Market Worth Billions 29 Product Focus: Sterilization 34 CE Article: Mechanical Ventilation and Weaning

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OUT OF THE OR 46 Spotlight On: Lisa VanDeer, RN, CNOR 48 Fitness 50 Health 53 EQ Factor 54 Nutrition 56 Recipe 58 Pinboard 60 Best of 2020 OR Today Webinars

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INDUSTRY INSIGHTS

news & notes

Healthmark Offers UVC LED Box Healthmark Industries recently added UVC LED Boxes to its Personal Protection Equipment (PPE) product line. Both boxes contain UV-C LED bulbs that generate ultraviolet beams with wavelengths of 260-280nm, which are effective in sanitizing personal items, such as phones, keys, etc. UVC-001SK has measurements of 216 x 104 x 71mm, and UVC-002SK has measurements of 302 x 269 x 154mm. For a limited time only, with the purchase of any UVC LED Box, 10 Ultraviolet Indicators (UVI-001SK) will be included at no additional cost. These indicators are a great way to verify the function of the UVC LED Boxes. The package of 10 comes with a color change reference guide to interpret the test results. •

Encompass Introduces Covaire Clear Barrier Drape Encompass Group LLC has announced Covaire, a new product that helps contain viral aerosols using a clear plastic disposable barrier. Covaire provides visual access with ease of maneuverability while further protecting the health care worker from aerosolized particles during high risk aerosol-generating procedures. It’s an additional layer of protection to compliment providers’ current PPE. Covaire is generously sized – adequate length and girth for a bariatric patient – and made of a clear, medical grade film that’s safe, comfortable and lightweight. With its contoured silhouette, Covaire tucks under the patient’s head, covering the temporal and ear regions. A curved opening on each side allows the provider to insert his/her arms for a full range of movement without restriction when operating an apparatus, intubating or extubating. COVAIRE does not move while in use. Once a procedure is complete, Covaire folds up, aerosolized viral particles are contained on the product and can be safely disposed of. •

ReadySet Surgical Launches RS Capture ReadySet Surgical has launched RS Capture, enhancing the company’s cloud-based, end-to-end platform to optimize hospital surgical supply chain management. RS Capture guarantees that hospital supply chain leaders can prevent off-contract implant utilization, resulting in more cost-efficient surgeries for the hospital and patient. By documenting and validating all vendor submitted implant charges against the contract Item Master prior to submission, RS Capture accelerates the revenue cycle by processing surgical invoices up to four times faster with 100% accuracy. It is estimated that billions of dollars in “bill-only” implant charges contain errors, so health systems are forced to expend significant resources to resolve inaccurate billing data which ties back the patient’s medical record.

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DECEMBER 2020

“Managing the surge in procedural demand that many hospitals are experiencing underscores the need for a well performing surgical supply chain,” says ReadySet Surgical’s Founder and CEO Keerthi V. Kanubaddi. “There simply is no room for inefficiencies, particularly as hospital financial losses are projected to deepen by year end.” RS Capture builds on ReadySet Surgical’s existing solutions, RS Track, which documents and tracks loaner and consignment surgical inventory, and RS Coordinate, which is integrated into the surgical scheduling platform (EMR) and provides real-time alerts related to upcoming patient procedures. • For more information, visit www.readysetsurgical.com.

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INDUSTRY INSIGHTS

news & notes

Lumenis Inc. Unveils Its First-Ever U.S. Tour Via LuMobile Lumenis Inc., an energy-based medical device company for aesthetic, surgical and ophthalmic applications, has announced its first-ever mobile tour (LuMobile). The tour continues through April 2021. The company will bring its flagship devices to practitioners in a safe environment aboard the new LuMobile outdoor tradeshow exhibit. The 20-city mobile tour will kick off in Chicago and make its way to New York, Los Angeles, Miami, Detroit, San Francisco and many more major cities around the country. Lumenis conceived the LuMobile in response to the COVID-19 pandemic, which has limited opportunities for physicians and other practitioners to get in-person experiences with new technologies. To fill the void, the LuMobile will take the newest and most popular Lumenis technologies across the country, including the new Stellar M22 for aesthetics, the newly launched MOSES 2.0 surgical platform, and the Selecta DUET and Optima IPL ophthalmic devices. When the LuMobile’s super-sleek, glass-encased mobile tradeshow booth rolls into town, professionals will watch live demos, talk with Lumenis representatives and experience the devices for themselves.

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Attendees will also find fun red-carpet events, ribbon-cutting ceremonies, food trucks and more. “When all educational meetings and trade shows came to a halt this year, we started thinking of new ways to safely bring physicians together in a professional venue to continue to advance education, patient care and new breakthroughs in medical technology,” said Brad Oliver, regional president of the Americas. “By providing an outdoor, social-distanced tradeshow environment, we are providing a safe setting to continue to advance education on recent medical innovations. Attendees can enjoy themselves, while safely learning about new break throughs in medical technologies. It’s important we continue to advance medicine and share ideas collectively, especially during these challenging times. We believe our mobile, outdoor tradeshow creates that environment. I look forward to greeting our customers, friends and colleagues with smiles, masks and elbow handshakes.” • For more information, visit LumenisOnTour.com.

DECEMBER 2020 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

ASCs Reduce Medicare Costs by More than $4 Billion Each Year New analysis of Medicare payment data shows that ambulatory surgery centers (ASC) reduced Medicare costs by $28.7 billion from 2011 through 2018 by providing services to beneficiaries that otherwise would have been provided in higher-cost hospital outpatient departments (HOPD). The analysis, conducted by KNG Health Consulting LLC, also shows that, without any policy changes, procedures provided to Medicare patients in ASCs are expected to reduce program costs by an additional $73.4 billion from 2019 to 2028. Study data also shows that Medicare savings per year increased from $3.1 billion in 2011 to $4.2 billion in 2018. They are projected to be more than $12 billion in 2028. The analysis also projects that an expected shift in a percentage of total knee arthroplasties from the HOPD to the ASC setting will result in an additional $2.95 billion in savings to the Medicare program between 2020 and 2028. Medicare did not reimburse ASCs for providing this procedure to its beneficiaries before 2020. “This study provides data that Medicare officials and everyone committed to reducing the cost of health care need to consider,” says ASCA Chief Executive Officer William Prentice. “With a few policy changes to encourage the migration of more procedures into the ASC setting, Medicare savings could accelerate, and more Medicare patients would have access to the quality care that ASCs offer.” While most of the savings from 2011 to 2018 are attributed to a stable group of high-volume procedures, especially cataract surgeries and colonoscopies, projected savings for 2019 to 2028 are expected to be driven by growing specialties such as endocrine, cardiovascular and orthopedic surgery. Four specialty areas — eye and ocular adnexa, cardiovascular, nervous system and digestive system surgery — each accounted for more than $3 billion in total savings from 2011 to 2018. By 2028, five specialty areas — eye and ocular adnexa, cardiovascular, nervous system, digestive system and musculoskeletal surgery — are each projected to save Medicare more than $1 billion per year. More information about the study, the methodology used to conduct the analysis and the analysts’ findings is available in the full report Reducing Medicare Costs by Migrating Volume from Hospital Outpatient Departments to Ambulatory Surgery Centers. •

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Caresyntax, AORN Introduce Performance Guarantee to Increase Operating Rooms’ Efficiency Caresyntax and the Association of periOperative Registered Nurses (AORN) have partnered to launch a performance guarantee program for their operational analytics solution to make operating rooms (OR) more efficient. As health care systems continue to struggle during the COVID-19 pandemic, adding a performance guarantee helps administrators and perioperative leaders make better decisions and achieve better patient outcomes. Over the past three years, data from ORs across the U.S. has shown that caresyntax’s Periop Insight, the exclusive analytics solution of AORN, dramatically increases utilization and efficiency rates, allowing health care systems to improve their financial outcomes. The new program will contractually guarantee savings over a one-year period for any hospital or health care system that utilizes the platform. “Today more than ever, hospitals and surgery centers are stretched to the brink as we all try to overcome the challenges of COVID-19,” said Dennis Kogan, co-founder, chairman and CEO of caresyntax. “In working closely with AORN and our customers, we’ve helped hospitals around the country deliver better care to patients during this challenging time, and we’re excited to further expand our impact by introducing this performance guarantee program.” Caresyntax has developed an online ROI calculator to help health care leaders better understand how Periop Insight can help their organizations reduce costs. The web-based tool collects basic information from hospitals or surgery centers, including case volume, number of ORs and specialty areas. Within minutes, OR administrators can see where operational improvements and costs savings could be improved. •

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INDUSTRY INSIGHTS

news & notes

STERIS ACQUIRES KEY SURGICAL STERIS plc has signed a definitive agreement to purchase Key Surgical, a portfolio company of Water Street Healthcare Partners LLC, through a U.S. subsidiary for $850 million. STERIS anticipates that the acquisition will qualify for a tax benefit related to tax deductible goodwill. Adjusting for the present value of the anticipated tax benefit, the purchase price is effectively reduced to approximately $810 million. Key Surgical, founded in 1988, is a global provider of consumable products serving hospitals and surgical facilities. Annual revenue for Key Surgical in calendar 2020 is anticipated to be approximately $170 million, with adjusted EBIT of approximately $50 million. “Key Surgical strengthens, complements and expands STERIS’s product offering and reach around the globe. Their focus on the sterile processing department, operating room and endoscopy fits perfectly with our core health care customers,” said Walt Rosebrough, president and chief executive officer of STERIS. “The business has demonstrated an ability to grow at rates above industry levels with its product portfolio breadth, a steady stream of new products and a highly effective commercial model. We welcome the Key Surgical people to the STERIS

team, and we look forward to working together to enhance our service to our customers and the value for our shareholders.” “Our companies are a great fit – we truly complement and strengthen STERIS’s product offering around the globe. Over the last 32 years, Key Surgical has developed a strong brand with a diverse product portfolio, continual expansion of new products and effective commercial model. We’re excited and look forward to the great potential this combination brings.” Rosebrough added. Under the terms of the agreement, STERIS will purchase the shares of Key Surgical at closing. The transaction will be financed through a combination of debt and cash on hand and is anticipated to close by December 31, 2020 pending customary closing conditions and regulatory approval. The transaction is expected to be immediately accretive to STERIS’s adjusted earnings after close and add approximately $40 million to revenue and about $0.10 to adjusted earnings per diluted share in STERIS’s fiscal 2021 fourth quarter. STERIS expects to realize annualized pre-tax earnings synergies of $10-$15 million by year three following the close.•

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INDUSTRY INSIGHTS

news & notes

CycleTrak Robotic Module Tracks Robotic Instrument Reprocessing Cycles InstruSafe by Summit Medical, an Innovia Medical Company, announced the U.S. availability of its new CycleTrak Robotic Module, which is a system that allows users to track individual reprocessing cycles for all robotic instruments and accessories. Developed in partnership with Practico Solutions, CycleTrak is a compliance solution that tracks and records individual reprocessing cycles for da Vinci Xi, Si, SP instruments and accessories. CycleTrak was created as a direct response to the FDA’s recent guidance that states “devices with a specific maximum number

of reprocessing cycles not be exceeded.” CycleTrak differs from traditional instrument management solutions through its affordable one-year subscription, simplistic design that uses existing hardware and quick implementation time of days versus weeks or months. • For more information, visit https://www.instrusafe.com/da-vincisolutions/.

Joint Commission, Hospitals Partner to Reduce HAPI A collaborative project to address hospital-acquired pressure injuries (HAPI) has resulted in more than a 60% reduction in a common but preventable issue that claims over 60,000 U.S. lives each year. Led by the Joint Commission Center for Transforming Healthcare, the improvement initiative – including The Johns Hopkins Hospital, Kaiser Permanente South Sacramento Hospital and Memorial Hermann Southeast Hospital – saw these significant reductions sustained even as the COVID-19 pandemic accelerated in the United States. The project launched to identify solutions to prevent and reduce the rate of pressure injuries, also known as decubitus ulcers or bedsores, in health care facilities after seeing that HAPI were rising nationally. Experts estimate more than 2.5 million patients in U.S. acute-care centers experience pressure ulcers and injuries each year. Because pressure injuries are a significant risk for immobile patients, the country is experiencing a jump in this condition as COVID-19 patients require long hospitalizations. Using Robust Process Improvement (RPI) – a proven combination of Lean, Six Sigma and formal change management – the Center worked with participating hospitals to determine and address root causes that contribute to pressure injuries in their facilities. Because many different factors contribute to any given problem and can vary across organizations and even units, understanding the elements contributing to a problem is critical to successfully solving it. The three participating organizations identified their own unique contributing factors across the facility and, using RPI in collaboration with Center experts, implemented a plan for improvement. Organizations achieved an average 55% relative reduction in intensive care unit pressure injuries from May 2018 to December 2019. They continued building on that momentum

12 | OR TODAY |

DECEMBER 2020

from January to April 2020, experiencing a 62% average relative reduction and preventing 78 pressure injuries annually. This outcome resulted in a cost savings in aggregate of $15.3 million for the length of the project by reducing an expensive condition that costs the health care industry $11 billion a year. “Our staff have become more aware of the outcome of improvement work and how it helps them save a life – but they’re saying that’s not enough,” said Rachel Wyatt, RN, BSN, MHA, clinical adult services director for Kaiser South Sacramento Medical Center. “We’ve seen an incredible shift in our focus and culture around this issue to ask: How do we save a whole person and make sure to protect their quality of life?” The pressure injuries improvement project is one of many undertaken by the Center, created in 2008 to drive high reliability health care by empowering teams with the knowledge and tools needed to address the industry’s most pressing quality and safety issues. “Tackling a persistent issue like hospital-acquired pressure ulcers and injuries requires strong leadership, vision and a deep commitment to pushing toward zero harm,” said Anne Marie Benedicto, vice president of the Joint Commission Center for Transforming Healthcare. “The Johns Hopkins Hospital, Kaiser Permanente South Sacramento Hospital and Memorial Hermann Southeast Hospital are seeing the measurable – and immeasurable – benefits of using a successful improvement methodology to improve outcomes. We hope to see continued momentum in this space as other organizations see what is possible.” • For more information, visit www.centerfortransforminghealthcare.org.

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INDUSTRY INSIGHTS

news & notes ECRI: Up to 70% of Chinese KN95 Masks Tested Don’t Meet Minimum Standards An analysis by the nation’s largest patient safety organization shows that up to 70 percent of KN95 masks tested do not meet U.S. standards for effectiveness, raising the risk of contracting COVID-19 for care providers and patients at hospitals and other health care organizations that imported masks from China. Researchers at ECRI, a not-for-profit organization that for decades has advised hospitals, government organizations and other health care stakeholders on product safety, found that 60 to 70 percent of imported KN95 masks do not filter 95 percent of aerosol particulates, contrary to what their name suggests. Early indication from ECRI’s testing of nearly 200 masks, reflecting 15 different manufacturer models purchased by some of the largest health systems, raised alarms for ECRI, which issued a high priority hazard alert. The testing was done according to rigorous product testing protocols, conducted by ECRI’s quality assurance researchers at the organization’s independent medical device laboratory. “Because of the dire situation, U.S. hospitals bought hundreds of thousands of masks produced in China over the past six months, and we’re finding that many aren’t safe and effective against the spread of COVID-19,” said Marcus Schabacker, MD, Ph.D., ECRI’s president and chief executive officer. “Using masks that don’t meet U.S. standards puts patients and frontline health care workers at risk of infection. As ECRI research shows, we strongly recommend that health care providers going forward do more due diligence before purchasing masks that aren’t made or certified in America, and we’re here to help them.” As U.S. health care providers felt forced to fend for themselves in the early days of the pandemic amidst a massive shortage of personal protective equipment (PPE) for their workers, they turned to

thousands of companies newly registered in China to manufacture KN95 masks. Despite a recent increase in government-supported PPE production in the United States, including manufacturing N95 masks, hospitals and health systems continue to report widespread shortages on quantities that can be purchased, causing providers to keep purchasing imported KN95 masks that do not meet U.S. regulatory standards. Hospitals report significant challenges ordering American-made masks, with some believing they are competing with the U.S. government as it seeks to replenish its PPE stockpile. Although the majority of imported KN95 masks do not meet the U.S. National Institute for Occupational Safety and Health (NIOSH) N95 standard, ECRI researchers say the KN95s can be used in lieu of surgical or procedure masks for activities that involve limited contact with bodily fluids (because KN95s are not intended for fluid repellency), and they may provide superior respiratory protection. ECRI warns U.S. health care organizations, however, to use KN95s or other non-NIOSH-certified masks only as a last resort when treating known or suspected COVID-19 patients. “KN95 masks that don’t meet U.S. regulatory standards still generally provide more respiratory protection than surgical or cloth masks and can be used in certain clinical settings,” said Michael Argentieri, vice president for technology and safety at ECRI. “Hospitals and staff who treat suspected COVID-19 patients should be aware that imported masks may not meet current U.S. regulatory standards despite marketing that says otherwise.” While not providing 95 percent protection, ECRI researchers say many non-certified masks that have head and neck straps, as opposed to masks with ear loops, better conform to and seal against the wearer’s face, ensuring that air being breathed is filtered. •

Medtronic Announces Adaptix Interbody System Medtronic plc has announced the U.S. launch of Adaptix Interbody System, the first navigated titanium implant with Titan nanoLOCK Surface Technology, a proprietary blend of surface textures on the macro, micro and nano levels. The Adaptix Interbody System, mirrored after the veteran Capstone Spinal System, touts improved features for increased strength, subsidence resistance, easy insertion and data-backed bone growth, according to a news release. The announcement was made during the virtual edition of the North American Spine Society (NASS) annual meeting. Adaptix received U.S. Food and Drug Administration (FDA)

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approval in August 2020. This milestone represents the first 3D printed titanium implant, developed in house by Medtronic engineers, that incorporates the state-of-the-art Titan nanoLOCK Surface Technology. The Adaptix Interbody System addresses surgeons’ universal needs of fusion outcomes and offers: • Trusted design with enhanced features. • Science-backed nano surface technology. • Navigation efficiency and confidence.•

DECEMBER 2020 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

Olympus to Distribute Ultravision Surgical Smoke Management System Olympus has entered into an exclusive agreement with Alesi Surgical Limited to distribute the 510(k)-cleared Ultravision surgical smoke control system in the U.S. Surgical smoke is a gaseous byproduct of tissue treated with electrical surgical devices, which are used for cautery, cutting, and ablation, among other uses. If not properly managed, surgical smoke can be hazardous to the health of people working within the surgical suite. Physicians and nurses recommend using a smoke management device to reduce the risk of potential exposure to aerosolized contaminants, and two U.S. states have passed laws mandating that hospitals install local exhaust ventilation systems in procedure rooms to control smoke and reduce the risk of staff exposure, with other state legislation pending. In the United States, Ultravision is cleared for use in laparoscopic and open surgery. Ultravision suppresses the aerosolization of surgical smoke and mist using the highly characterized process of electrostatic precipitation. Clinical research has shown that

Ultravision improves visibility, prevents the release of surgical smoke into the operating room, reduces patient CO2 exposure and facilitates “low pressure” laparoscopic surgery. “Using an effective surgical smoke management device is essential to minimizing the risk of exposure for surgical teams in the operating room,” said Ross “Rusty” Segan, MD, MBA, FACS, chief medical officer for Olympus Corporation. “Health care professionals are rightly concerned about risks posed by bioaerosols, especially during the pandemic. However, we must find safe ways to continue performing surgical procedures using minimally invasive techniques because of the significant clinical benefits this type of surgery offers patients. With its unique and highly characterized mode of action, Ultravision offers an innovative means to control bioaerosols during laparoscopic surgery.” • For more information, visit www.alesi-surgical.com.

Virginia ASC Deploys Germ-Zapping Robot As health care facilities look for new and innovative ways to battle multi-drug resistant organisms that can pose a risk to patient safety, Urosurgical Center of Richmond has taken a leap into the future with a LightStrike Germ-Zapping Robot named Rosie that destroys hard-to-kill viruses, bacteria and superbugs in hard-to-clean places. Urosurgical Center of Richmond is the first ambulatory surgery center (ASC) in Virginia to deploy a LightStrike robot from Xenex. The LightStrike robot is proven to deactivate Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, on surfaces in two minutes. “Our goal is to provide the safest possible environment for our patients. Urosurgical Center of Richmond already has a comprehensive infection prevention program in place, and we are very excited about adding this robot to our infection prevention protocol. LightStrike operating room disinfection is an additional step we are taking to enhance the safety of our patients, which has always been our top priority,” said Kent Rollins, MD, president of Virginia Urology. LightStrike Germ-Zapping Robots use pulsed xenon, an environmentally friendly inert gas, to create intense bursts of

14 | OR TODAY |

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ultraviolet (UV) light that quickly destroys bacteria, viruses and spores on hospital surfaces. The robot works quickly and does not require warm-up or cool-down time, so Urosurgical Center of Richmond is able to disinfect its operating suites quickly after each case. More than 40 peer-reviewed studies have been published validating the efficacy of the LightStrike technology. Rosie, the portable LightStrike robot, can disinfect the operating suites or procedure rooms in 10-15 minutes without warm-up or cool-down times. Operated by the surgery center staff, it can be used in any area of the ambulatory surgery center including operating suites, pre and postsurgical areas, restrooms and public spaces. •

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Infusion Pump Support & Power Solutions RTI Surgical Receives 510(k) Clearance for DAC Plate RTI Surgical recently received 510(k) Clearance from the U.S. Food and Drug Administration (FDA) for the Dynamic Active Compression (DAC) plate to provide stabilization and fixation of small bones of the foot. The DAC plate addresses an unmet need in the foot and ankle market and represents RTI Surgical’s first 510(k) Clearance since the company became an independent player with the support of Montagu. “The DAC plate is designed to improve fusion procedures in the foot by combining the rigid stability of a plate with Nitinol’s ability to provide continuous compression and ensure apposition of the bony surfaces during healing,” said Dr. Constantine Demetracopoulos, Hospital for Special Surgery. The system’s simplicity also provides for surgical application using minimal, straight-forward steps which address challenges of current standard plate and Nitinol staple options, without the complexity associated with more advanced options. “The DAC plate is a prime example of how we are able to leverage our core capabilities to enter a new market. Our trauma experience was crucial in creating the first hardware product we specifically designed for lower extremities in the foot and ankle space. We look forward to continuing to bring new technologies to the market to address unmet needs and help patients,” said Jimmy Blanchard, vice president of sales. •

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DECEMBER 2020 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

Diversey Announces MoonBeam3 Effective Against SARS-CoV-2 Diversey, Inc. has received confirmation through third-party testing that MoonBeam3 UV-C disinfection technology is effective in just seconds against SARS-CoV-2, which causes COVID-19. MoonBeam3 is an ultraviolet-C disinfection device that adds assurance beyond manual cleaning and disinfection. This portable, powerful solution disinfects quickly, reliably and responsibly. MoonBeam3 is cost-effective and designed for fast disinfection of public and high-risk areas. The system offers three individually adjustable arms that can be positioned at almost any angle, optimizing disinfection energy to allow dosing of both horizontal and vertical surfaces, in just three minutes. MoonBeam3 has undergone third-party testing against several microorganisms including enveloped viruses, small non-enveloped viruses, bacteria and bacterial spores. These tests have demonstrated a significant log reduction in these key pathogens. Since studies have shown that contamination of environmental surfaces in health care facilities with SARS-CoV-2 viral RNA is widespread, Diversey commissioned third-party testing of MoonBeam3 in the U.S., and has also partnered with the highly respected Fujita Health University in Japan, to test the effectiveness of the MoonBeam3 against SARS-CoV-2. The completed test results from Japan proved that MoonBeam3 was effective against SARS-CoV-2 under a range of conditions with contact times as low as four seconds for a 6-log reduction. This study validates that MoonBeam3 is effective against SARS-CoV-2, the pathogen that causes COVID-19.•

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DECEMBER 2020

Ambu Awarded GPO Contract Ambu Inc. has been awarded a national single-use endoscopy contract in the category of single-use endoscopes with a major U.S. group purchasing organization (GPO). The agreement is for the single-use endoscopy category and enables Ambu to serve approximately 20% of the acute care hospitals in the United States. This agreement will further accelerate Ambu’s rapidly expanding share of the singleuse endoscope market by giving those accounts pre-negotiated pricing and terms for Ambu’s full suite of endoscopy products. This comprehensive category will provide access to the full Ambu portfolio of FDA-approved single-use endoscopes and allow members the choice to partner with Ambu by standardizing across Ambu’s single-use product portfolio – including bronchoscopy, ENT, urology and gastroenterology.

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IAHCSMM

Key Updates to AORN’s Guideline for Care and Cleaning of Surgical Instruments By Susan Klacik, BS, CRCST, CIS, CHL, ACE, FCS n October, the Association of periOperative Registered Nurses (AORN) released its newly revised “Guideline for Care and Cleaning of Surgical Instruments,” and numerous changes directly impact the sterile processing (SP) discipline.

Specifically, this document provides evidence-based guidance for cleaning surgical instruments, including point-of-use treatment, transport, decontamination, inspection and general care of reusable medical devices.

Emphasis on SP environment Several changes to the guideline will have an impact on the quality of processing in SP areas. Note: Industry changes that occurred since the previous revision of this guideline are reflected in this updated version. One change pertains to the SP environment’s heating, ventilation and air conditioning (HVAC) parameters. The guidelines have been changed to recommend that the HVAC system be designed in accordance with the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) and local regulatory requirements to reduce the number of environmental contaminants and provide a comfortable environment for occupants in the area. Additional changes to the guideline include replacing the recommendation for “medical-grade compressed air” with “instrument air,” and replacing the recommendation for “treated water” with “critical water.” The previous version of

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the guideline offered specific recommendations for the design of the SP area; these design features are now outlined in the “AORN Guideline for Design and Maintenance of the Surgical Suite.” A key addition to the “Guideline for Care and Cleaning of Surgical Instruments” addresses pre-purchase evaluation. Many SP professionals have been concerned that they may not be included in the purchase decision of medical devices – a perplexing oversight given that some devices may be sophisticated and complex and require numerous timeconsuming processing steps that require SP technicians to have a higher skill level. This is now addressed under Recommendation 1.3. Pre-Purchase Evaluation. Another new recommendation is that the manufacturer’s written instructions for use (IFU) should be evaluated before the purchase and use of reusable surgical instruments and other medical devices, to determine whether the processing methods can be performed as stated in the IFU. The revised guideline also addresses personnel education and competency needs and assurance that the time required for all processing can be allocated. Having resources to properly process instrumentation continues to be addressed under 1.3: “Before purchase and use of reusable surgical instruments and other medical devices, determine whether the resources are available to perform the processing methods provided in the manufacturer’s validated IFU, including a listing of necessary resources equipment needed for transport methods to the decontamination area and environ-

mental conditions required for handling and storage.” The previous recommendation stated that, “Some instruments may require special cleaning, packaging, sterilization or maintenance procedures that cannot be provided by the facility without modifications to processes and equipment.” The updated recommendation now includes the consideration of a need to modify space. A key addition to the Sterile Processing Area section under Recommendation 2 involves consideration of sinks used in the decontamination area. Specifically, the recommendation states that the decontamination area should have the appropriate number, size and configuration of sinks, with the sinks being at a height that is ergonomically correct for those who perform manual cleaning (in accordance with the manufacturer’s IFU for items that will be processed). The recommendations also state that the sink should be marked at the water level needed for cleaning solution measurement, and a process for frequent cleaning of sinks and the sink area needs to be in place.

An eye on water quality Recommendation 4, Cleaning Products and Equipment, provides more focused guidance on the type of water to use (poor water quality results in reducing the effectiveness of some disinfectants and cleaning chemicals, and chlorine can pit stainless steel instrumentation). A new recommendation is that the health care organization should have a water management program in place that encompasses the utility water and critical WWW.ORTODAY.COM

INDUSTRY INSIGHTS

IAHCSMM water used during decontamination; the SP department should be included in that program; and a collaborative team consisting of clinical engineering personnel, facility engineering personnel and infection preventionists should establish a process and frequency for monitoring water quality. The updated guideline also provides recommendations – in a table format – for specific substances that should be monitored and controlled for critical and utility water. New recommendations have been added for the loaned instrument section that begins with forming an interdisciplinary team that is appointed by the health care organization to establish standard operating procedures for managing loaned reusable surgical instruments. Also, the revised guideline’s “Cleaning After Use” recommendation has been replaced with “Point-of-use Treatment,” terminology that is reflected in other guidelines and standards. The purpose of this change it to include all steps that need to occur at the point of use. Recommendations for point-of-use treatment include removing gross soil from instrument surfaces with a sterile radiopaque surgical sponge moistened with sterile water during the procedure. The use of saline to wipe instruments is still NOT recommended. Lumened instruments should be irrigated with sterile water at frequent intervals during the procedure.

Safer device and solution handling The guideline states that sharp instruments should be separated from other instruments and confined in a punctureresistant container before transport to the decontamination area. Disposable sharps such as scalpel blades and suture needles should be removed and discarded into a closeable, puncture-resistant container that is leakproof on its sides and bottom and labeled or color coded as “Biohazardous.” Instruments should be kept moist until they are cleaned by using either saturation with an enzymatic pretreatment product or a towel moistened with WWW.ORTODAY.COM

water placed over the instruments. During the instrument manual cleaning process, it is recommended to change the cleaning solution per the cleaning solution manufacturer’s IFU or between each use (if the manufacturer’s IFU does not make a recommendation). This is because bioburden deposited in the cleaning solution during the cleaning process can interfere with cleaning process effectiveness, and frequent changes of the cleaning solution can help minimize bioburden. Also, the cleaning solution should be changed when the solution temperature does not meet the temperature specified in the manufacturer’s IFU. Water should not be added to existing solution because it would dilute the cleaning solution concentration. There is also the recommendation to use cycles that exclude the use of lubricants in mechanical washers for instruments and devices that are not compatible with lubricants, such as orthopedic implants. Additionally, recommendations related to ultrasonic cleaners have been expanded and now include using accessories that are compatible with the ultrasonic cleaner, such as a metal open weave basket. This is because porous materials, such as silicone mats, can absorb the cavitation, negating its effect. Borescopes (a relatively new inspection tool for use in health care instrument processing) are now recommended for use during the inspection phase of surgical instrumentation for lumened devices. This is because it is difficult, if not impossible, to visualize the inner walls of lumened devices; therefore, an endoscopic camera or borescope can make it easier to detect soil.

prions. Processing eye instrumentation requires special methods to prevent toxic anterior segment syndrome (TASS), a non-infectious acute postoperative anterior segment inflammation caused by a noninfectious substance that enters the anterior segment, resulting in toxic damage to intraocular tissues (this condition appears to be related to instrument processing). Based on recent research, an additional support for processing eye instrumentation has been added to the section Intraocular Ophthalmic Instruments, which recommends keeping the ophthalmic viscoelastic (OV) and organic material moist to aid in their removal. This supports the continued recommendation to wipe ophthalmic instruments with sterile water and a clean lint-free sponge or cloth, and flush or immerse them in sterile water, in accordance with the manufacturer’s written IFU (a process that should be done immediately after use during the procedure). Another change that may need to be implemented when processing eye instrumentation is that some intraocular instrument manufacturers’ IFU may require dedicated ultrasonic cleaners that are not used for other types of instruments. This article has highlighted some (but certainly not all) of the major changes to the updated “AORN Guideline for Care and Cleaning of Surgical Instruments.” This based guideline is available to AORN electronic subscribers on eGuidelines+ and will also be included in the “2021 Guidelines for Perioperative Practices” print edition of the “Guidelines for Perioperative Practice.”

Prion and TASS precautions Recommendation 13, Prion Disease Transmission Precautions, recommends consulting the mechanical washer-disinfector manufacturer for instructions on decontaminating the mechanical washerdisinfector after processing instruments that may have been contaminated with

Susan Klacik, BS, CRCST, CIS, CHL, ACE, FCS, is a clinical educator at IAHCSMM.

DECEMBER 2020 | OR TODAY |

INDUSTRY INDUSTRY INSIGHTS INSIGHTS Surgery Starts news Here & notes

One Giant Leap for Infection Prevention By Brandon Huffman, BS, CRCST, CIS f there is anything 2020 has shown us, it’s that even the tiniest of life forms can overburden our already fragile health care systems. We work so hard every day to fine tune our practices, reduce surgery turnover times, shorten each patient’s length of stay and reduce staff overtime while improving overall patient outcomes. However, all that great work can be undermined by simple infection prevention shortcomings, especially amidst a global pandemic. In case you weren’t following, I am referring to the COVID-19 global pandemic.

As an infection preventionist, I spend a large amount of my time educating staff, patients and even friends and family on breaking the chain of infection. It’s easy to look back at the old chain of infection diagram and maybe you can even quote the six links to target in order to stop transmission, but translating that into work and life can be challenging for many people. Most of the time, we as humans fail to understand how many different surfaces we have touched on our way to the cafeteria, or how many times a day we touch our mouths. This doesn’t even consider the contaminated hand of that person you just shook, how is their germ awareness? I can hear my fellow germophobes chiming in with an “amen.” The fact of the matter is that as a society we have allowed the busyness of everyday life and work to cloud our judg-

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ment on infection transmission. If you were to take a survey of hospital workers, it would not be difficult to conclude that the majority envision a hospital as a dirty and prime location to encounter bacteria or viruses. But if you take that same group of people, how would they answer regarding their own home? Or better yet their best friends’ home in which they watched the football game last weekend as they shared chips and dip? In the operating room and sterile processing departments specifically, these breaks in transmission concepts can be overlooked and put patients and staff at risk. Consider instruments and scopes that cannot be put through a washer disinfector in the sterile processing department. Some manufacturers will provide a validated chemical agent to disinfect the item in order to make it safe to handle for technicians during the assembly and inspection process. Whereas, some manufacturers do not provide an approved method for disinfection at all. In these instances of missing disinfection standards, are your sterile processing technicians wearing gloves to assemble and inspect these items? Is the tabletop surface area used to assemble the instruments being wiped down and disinfected after the assembly process to prevent contamination to others? Let’s talk about the operating room in the middle of a colectomy case. Once the surgeon has performed an anastomosis of the colon, does anyone ask him or her to change their gloves before they inspect the rest of the bowel? Gut bacteria spread inside the abdominal cavity can develop a serious and possibly

deadly surgical site infection. Infection prevention is not just a fancy job title on a few of our signature blocks, it is a duty of all health care workers that we must continually uphold. Through all the doom and gloom of this global pandemic, I have seen the best in so many people shine through. Our inner human capacity to love and help is still present and flourishing. I am encouraged by all our brave health care workers who show up for our patients every single day in the face of this current adversity. But the greatest “silver lining” I have found as it relates to infection prevention is the giant leap forward in education about hand hygiene and basic infection transmission principles. Though the accuracy of the information at times isn’t always on point, the general existence of people willing to educate themselves and learn about preventive practices is more than I could ask for. It is my hope that this newfound interest in infection prevention continues as we endure our next flu season. We will get through this pandemic together. Stay consistent and be relentless.

Brandon Huffman, BS, CRCST, CIS, is an infection preventionist and quality and improvement professional for the PeaceHealth Oregon Network.

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INDUSTRY INSIGHTS CCI ASCA

Three Studies Demonstrate Value ASCs Deliver to Public, Private Insurers By Bill Prentice hree important studies released recently contain findings that everyone interested in improving patient access to lower cost, highquality outpatient surgical care should know.

The first study looks at Medicare cost reductions generated from 2011 to 2018 when the outpatient surgery procedures the program’s beneficiaries needed were provided in ASCs rather than hospital outpatient departments (HOPD). Then, it projects expected savings into 2028, with a special focus on total knee arthroplasty (TKA). The second study examines patient safety in ASCs since the COVID-19 public health emergency was declared earlier this year, and the third looks at the high level of quality and cost savings ASCs are able to offer private health insurers for an important group of gastroenterology procedures. Let’s take a closer look.

ASCs Reduce Medicare Costs by Billions Each Year, Able to Cut Spending Even More The first study, “Reducing Medicare Costs by Migrating Volume from Hospital Outpatient Departments to Ambulatory Surgery Centers,” is based on analysis provided by KNG Health Consulting LLC. The analysts who conducted the study looked at Medicare fee-for-service paid claims files to

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identify procedure-level paid amounts, outpatient procedure volumes and the share of outpatient procedures performed at ASCs. The analysts found that procedures performed in ASCs rather than HOPDs reduced Medicare’s costs by $28.7 billion during the eight-year period from 2011 to 2018 as annual savings grew from $3.1 billion to $4.2 billion annually. From 2019 to 2028, the analysts project, ASCs will reduce Medicare’s costs by another $73.4 billion as the program’s savings due to procedures performed in ASCs grow from $4.3 billion to $12.2 billion annually. To estimate future cost reductions tied to TKA and knee mosaicplasty, which were added to the ASC Covered Procedures List (CPL) in 2020, the analysts used the migration of partial knee arthroplasty (PKA) into the ASC setting when it was first approved for payment in ASCs as a model. Based on the PKA migration rates, the authors estimated that the ASC share of outpatient TKA and knee mosaicplasty would increase from 13.4 percent in 2020 to 18.0 percent in 2028, growing at 3.7 percent annually. At that rate, the savings ASCs could offer Medicare would total $2.95 billion. Even if the procedure migrated at only 25% of that projected rate, the savings would be $0.7 billion, and both of those figures would be

in addition to the $73.4 billion cost reductions ASCs are expected to offer over other procedures. In every case, Medicare could further reduce its future costs by enacting policies that encourage the migration of more procedures into the ASC setting. Some ideas ASCA supports include: • Continued use of the same factor – currently the hospital market basket – to update both ASC and HOPD payments for inflation each year • Appropriate payment rates for all device intensive procedures • Copay caps in ASCs that match those available in HOPDs • Elimination of a budget neutrality adjustment Medicare uses now to determine ASC payments that disincentivizes volume from migrating to ASCs and is contributing to a growing disparity in ASC and HOPD rates

ASCs Are Protecting Patients from COVID-19 The ASC Quality Collaboration (ASC QC) conducted the second study. Aiming to find out how safely ASCs have been able to provide care to their patients since the national COVID-19 public health emergency was declared earlier this year, the ASC QC surveyed WWW.ORTODAY.COM

more than 700 ASCs in eight states (CT, IL, LA, MA, MI, NJ, NY and PA). Three of those states (NY, NJ and LA) were already experiencing high rates of COVID-19 infection in their general population. A total of 84,446 patients were included in the survey. Only 16 of those patients tested positive for COVID-19 within 14 days after their procedure, an infinitesimally small infection rate of just .02 percent. It should also be noted that there is no way of actually knowing when or how the 16 patients became infected. What this survey data confirms is that ASCs, which had numerous safety protocols in place prior to the pandemic to prevent the spread of infections, can continue to perform essential surgeries without putting patients at greater risk of contracting COVID-19. Together with the additional COVID-19 safety measures ASCs have in place today, including heightened pre-operative screenings, additional sanitary measures and air filtration protocols, ASCs can maintain a safe, sanitary environment to treat patients, while keeping the health professionals providing their care protected.

Private Payer Data Shows Cost Savings and Quality The third study, provided by Anthem’s Public Policy Institute, looks exclusively at the commercial insurance market. For private payers, it concludes that, “Over the next decade, the U.S. health care system could realize savings of approximately $12 billion if one in five upper gastrointestinal (GI) and colonoscopy procedures were performed in ASCs rather than in HOPDs.” Anthem’s research examines claims from 3.7 million fully insured members of Anthem’s affiliated commercial health plans in calendar year 2019 across 14 states (CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, NY, OH, VA and WI). Savings estimates were based on allowed amounts to facilities (i.e., HOPDs and ASCs) and did not include professional fees or member liability through cost sharing. The analysts considered 26 procedure codes. The analysis also finds that “Shifting select procedures from a HOPD to an ASC produces the same quality outcomes and has the potential to be more convenient and less expensive for consumers. It may also benefit the health care system at large by reducing total costs and driving greater efficiency.” The report also says that, when it comes to creating savings for consumers, as well as for the overall health care system, by transitioning some procedures from hospital-based outpatient settings to ASCs, colonoscopy and upper GI procedures are just one piece of the potential savings. The more data we examine, the clearer it becomes: ASCs are economical, high-quality providers of outpatient surgery and the right choice for millions of patients each year. Insurance providers and government officials across the country and in Washington, D.C., should be doing all they can to promote policies that support patient access to ASCs. William Prentice is the chief executive officer of the Ambulatory Surgery Center Association.

YOU WOULDN’T WANT THIS IN YOUR OPERATING ROOM WHY ARE YOU SETTLING FOR FORCED AIR? IMAGINE EFFECTIVE PATIENT WARMING WITH NO NOISE, AIR MOVEMENT OR EXCESSIVE HEAT

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DECEMBER 2020 | OR TODAY |

INDUSTRY INSIGHTS CCI

Recruitment and Retention in the Surgical Suite By James X. Stobinski n my recent readings I came across two articles by Ed Hardin on the necessity of talent development and management for supply chain management professionals. Hardin speaks to the difficulty of retaining and developing talent in this field which is central to maintaining the efficiency of an operating room. These articles caught my attention as he used an analogy of developing talent in health care as baseball teams do in their farm systems. While Hardin makes a strong case in his specialty in both the 2019 and 2020 articles these same issues affect a diversity of health professions to include central processing and perioperative nursing.

It is difficult to attract talent to a role that is not well known. Perioperative nursing with its emphasis on technology, equipment and hands-on skill does not fit the typical vision of nursing held by many health care consumers. Although perioperative nursing is one of the largest specialties in nursing, many nursing students know little of the profession. The work of both central processing technicians and supply chain professionals, although vital to the work of surgery, are not highprofile jobs. Often, central processing is an entry level position in a health care facility and on-the-job training is used to orient new staff to this work. Hardin’s articles mesh nicely with a third article by Kumar and George written for a webpage hosted by the World Economic Forum. That article, “Why skills – not degrees – will shape the future

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of work,” has a logical connection to Hardin’s writing. Kumar and George assert that as the nature of work changes the right skills will be valued over just academic degrees and how well companies can shift to changing their orientation to skills-based training will factor into their future performance. These authors go on to say that the COVID-19 pandemic offers an opportunity to quickly, perhaps out of necessity, re-shape hiring practices. These disparate articles now lead us back to central processing technicians, supply chain management staff and perioperative nurses. All these professions work closely together in the operating room, but each now has a similar opportunity to change perspective on education and training processes. That is, to re-examine the value of skills and credentials versus a sole reliance on academic degrees. In central processing and in supply chain management, where degrees are not yet a common requirement, we could consider refining and standardizing education and training to better support these professionals in a dynamic and fast-changing environment. I do not advocate changing the well-established pre-licensure education courses for nursing that have served the profession well. However, I do think we have an opportunity to look at the education processes which bring registered nurses into the profession of perioperative nursing. The effectiveness of current methods for this lengthy, resource-intensive process have not been extensively studied and compared for effectiveness. This shortfall represents a rich research opportunity, and the Competency and Credentialing Institute Research Foundation (CCIRF) is just now beginning to

fund studies in this area. There is much to study and learn from the facilities that excel in recruiting and retaining staff. This incredibly disruptive pandemic will accelerate change and transition that might have otherwise been years away. One opportunity for nursing during these unsettled times is to begin to examine how we bring nurses into the profession and how we might improve those processes. Next month, I will share my thoughts on areas that perioperative nursing could address. This period of rapid change does offer openings for those with the wisdom to see the opportunity and the resources to attempt change.

References Hardin, E. (2019). A call to … [f]arms! Accessed October 1, 2020 at: https://www.hpnonline.com/ sourcing-logistics/article/21118036/a-call-tofarms. Hardin, E. (2020). Revamping supply chain’s farm system. Healthcare Purchasing News. 44(7). Pg. 60. Kumar, R. & George, S. (2020). Why skills - not degrees - will shape the future of work. Accessed October 1, 2020 at: https://www.weforum.org/agenda/2020/09/reckoning-for-skills/.

James X. Stobinski, PhD, RN, CNOR, CSSM(E), is Chief Executive Officer at Competency & Credentialing Institute (CCI).

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WEBINAR SERIES

news & notes webinars

Webinars Address Hot Topics he OR Today Webinar Series is nearing the 5,000-attendee mark in 2020. Health care professionals from throughout the United States continue to register for these insightful free webinars on a range of pertinent topics.

Forced Air Contamination Risk One of the popular OR Today Webinar Series presentations was the session “Forced Air Contamination Risk in the OR” sponsored by Encompass. It was eligible for one (1) continuing education (CE) hour by the State of California Board of Registered Nursing. This 60-minute webinar, presented by Victor R. Lange, was designed to help attendees understand the infection and cross-contamination risk associated with the use of forced-air warming on patients in the OR. Lange described a data correlation between forced-air warming device components and airborne contamination. He also directed attendees on how they can contribute to improved facility risk review and improved patient-warming and infection-prevention protocols. Lange also shared background on patient-warming benefits, provided a literature recap of forcedair warming risk, reviewed study objectives, methods, study results and conclusions. The webinar was a popular session with 110 attendees. A recording of the session is available online for on-

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demand viewing. Those in attendance for the live session provided feedback via a post-webinar survey. “This event had some very good information and data to support its findings,” a business founder and owner J. Harper said. “I thought the subject was timely since we are dealing with airborne transmissions like COVID-19,” explained V. Lewis, RN. “It was a very informative class. As a biomed, we change out the HEPA filters regularly. It was great to learn more about why it is so important,” Supervisor R. Modzelewski said.

Delayed Surgery Costs “The True Costs of OR Delays: A Review” shared insights with attendees. Michael Weissman, system director of sterile processing at UCSF Medical Center, presented the webinar that was eligible for one (1) continuing education (CE) hour by the State of California Board of Registered Nursing. The webinar addressed some of the causes and impacts of OR delays on hospitals, staff and patients. With COVID-19, it is estimated that more than 1 million elective orthopedic surgeries have been delayed, which will take 7-16 months to work off. Being efficient in the OR has never been more important. Almost 200 people registered to attend the live presentation and a recording of the session is available online. Attendees provided positive feedback via a post-webinar survey. The

presentation received a 4.3 rating on a 5-point scale with 5 being the best possible score. “This was a relevant topic to surgical services. The cost of OR delays being laid out was eye-opening,” OR Clinical Development Specialist A. Cuel said. “Very informative talk. Goes into detail about how something, seemingly a small issue, can cause such significant delay/effects,” said A. Amini, Staff Nurse 2. “I enjoyed the webinar as it referenced things that are asked all the time from executives. It provided great tools to use when the question arises again,” Manager J. Martinez said.

Reusable Medical Devices “Getting the Most Out of Your Reusable Medical Devices” presented by Kevin Anderson, BSN, RN, CNOR, CSSM, CRCST, CHL, CIS, CER, was a hit with attendees. It was also eligible for one (1) continuing (CE) hour by the State of California Board of Registered Nursing. Eligible for 1 credit for IAHCSMM and CBSPD. Health care professionals who work with surgical instruments know that much of their success depends on the ability to understand and handle surgical instruments. The main purpose of this webinar was to simplify the process of learning about surgical instruments and the issues that commonly occur with them. It addressed costs and the importance of proper care and handling of common reusable medical devices like stainless steel, laparoscopic instruments as well as WWW.ORTODAY.COM

flexible and rigid endoscopes. Anderson also discussed how the role each professional fills in the surgical services departments can better impact reusable medical device assets. More than 200 people registered for the webinar. Attendees provided feedback via a post-webinar survey that included testimonials for the OR Today webinar series. “The presenter was very clear, straight to the point, and used real situations/scenarios that occur in an SPD department,” shared J. Serrano, CRCST, CER and CIS. “OR Today never fails to present an awesome learning experience. Kevin Anderson did an outstanding presentation on the proper care and handling of instrumentations. Thank you for bringing these learning opportunities via webinars,” team lead A. Henke, OR, RN, CNOR, said. “Wonderful presentation. Enjoyed the slides with real-life examples,” Materials Manager K. Wilson said. For more information, visit ORToday.com and click on the “Webinars” tab.

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IN THE OR

market analysis

Global Sterilization Services Market Worth Billions Staff report MarketsandMarkets press release states that the sterilization equipment market is projected to reach $13.6 billion by 2025 from $12.1 billion in 2020, at a compound annual growth rate (CAGR) of 2.5% from 2020 to 2025.

â&#x20AC;&#x153;Market growth is largely driven by factors such as the growing global prevalence of lifestyle diseases such the rising incidence of hospital-acquired infections, increasing number of surgical procedures, and growing focus on food sterilization and disinfection. Emerging economies and re-introduction of ethylene oxide are expected to provide a wide range of growth opportunities for players in the market,â&#x20AC;? the press release states. The global sterilization services market is expected to reach $4.4 billion in 2027, according to a Globe Newswire report. The market is estimated to grow with a compound annual growth rate (CAGR) of 6.3% from 2020-2027. Factors driving the growth of the sterilization services markets are increasing prevalence of health care associated infections and an increasing number of surgical procedures worldwide. Also, growth in the medical device industry is likely to have a positive impact

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on the growth of the market in the coming years. In addition, development opportunities in emerging countries is expected to have a positive effect on the growth of the market in the forecast years. With various technological advancements in recent years, the medical device industry is projected to experience significant growth throughout the world. A growing need for better health care facilities means that many developing economies are relying on technology-enabled health care solutions. An increase in the elderly demographic of the world population, cases of chronic illnesses and pediatric care are factors increasing the demand for advanced health care facilities. Additionally, the presence of top revenue-generating medical device companies that continue to invest a significant amount in the research and development of advanced technologies and sterilization services is fueling the growth of the medical device industry across the world. Growth in the medical device industry, combined with stringent regulations, are creating opportunities for the key players in the sterilization services market. The global sterilization services market is segmented into ethylene oxide (ETO) sterilization, gamma sterilization,

electron beam radiation sterilization, steam sterilization, and other sterilization methods. The ethylene oxide (ETO) segment is expected to dominate the method segment market because of an extensive network of ETO sterilization service providers worldwide. Based on the service type, the contract sterilization services segment holds the largest share of the service type segment during the forecast period. Similarly, based on the mode of delivery, sterilization services are categorized as offsite sterilization services and onsite sterilization services. The offsite sterilization services segment holds the largest share of this segment during the forecast period. Based on the end user, sterilization services categories include medical device companies, hospitals and clinics, pharmaceutical and biotechnology companies, food and beverages and other end users. The medical device companies segment holds the largest share of the end user segment during the forecast period. The market for sterilization services is expected to grow, owing to factors such as an increasing number of surgical procedures worldwide. Moreover, development opportunities in emerging countries are likely to have a positive impact on the growth of the market in coming years. WWW.ORTODAY.COM

IN THE OR

product focus

Attest Vaporized Hydrogen Peroxide (VH202) Tri-Metric Chemical Indicator As the first and only VH2O2 chemical indicator in the FDA’s new multivariable product category for chemical vapor sterilization, the 3M Attest Vaporized Hydrogen Peroxide (VH202) Tri-Metric Chemical Indicator independently monitors the three critical variables of time, temperature and VH202 concentration. This will allow sterile processing departments to elevate the standard of care in VH2O2 to the level they currently expect in steam sterilization. The 3M Attest Tri-Metric Chemical Indicator helps ensure heat and moisture sensitive instruments such as robotic scopes and batteries are properly exposed to the critical variables of VH202 sterilization. With easy-to-read “accept” and “reject” zones, the indicator will clearly change from blue to pink to indicate results. • For more information, visit go.3M.com/sterilization.

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TD 100 Automated TEE Probe Disinfector CS Medical LLC is a leader in developing, manufacturing and marketing medical devices designed to provide cleaning and high-level disinfection of ultrasound TEE probes. Its core product, the TD 100 Automated TEE Probe Disinfector, is an example of an ongoing commitment to innovation and to the health and safety of medical patients and staff. The TD 100 eliminates manual reprocessing of delicate and expensive TEE ultrasound probes while providing a repeatable and FDA-cleared disinfection process. The TEEClean Automated TEE Probe Cleaner Disinfector will continue the TD 100’s work by automating the required cleaning process for the TEE probe before high-level disinfection. •

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DECEMBER 2020 | OR TODAY |

IN THE OR

product focus

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GSS67N Steam Sterilizer For medium capacity, the Getinge GSS67N Steam Sterilizer offers more of what you’re looking for in a mid-size unit including clean steam capabilities, plus the technology to reduce water and energy consumption at no extra cost. An optimized chamber design maximizes load capacity per cycle while reducing floor space requirements. •

Healthmark

Fight Wet Packs with UnderGuard Tray Liners UnderGuard Tray Liners are produced from pure cellulose ECF wood pulp, manufactured with low chloride and sulfate content and free from optical dyes, these liners can be safely used next to delicate instruments during sterilization to absorb and rapidly disperse condensate. This greatly facilitates the production of dry packs. • For more information, visit hmark.com.

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product focus

Key Surgical Tray Liners

While the process of surgical instrument sterilization usually includes the use of a container or a tray, often an additional product is needed to help with protection and absorption. That’s where Key Surgical Tray Liners come in. Made of strong, nonlinting polyester/cellulose blend material they are designed to absorb condensate created during the sterilization process to reduce the likelihood of the ever-feared wet packs. Wet packs are deemed contaminated which requires the entire set to be reprocessed; causing procedure delays and unnecessary wasted time and money. A proactive approach to sterilization should include using Tray Liners and with pre-cut sizes to choose from, you could say we’ve got you covered (or lined). • For more information, visit www.keysurgical.com.

oneSOURCE oneSOURCE, an RLDatix company, enables facilities to stay in compliance 24/7 through its robust online platform equipped with updated instructions for use (IFUs) and preventative maintenance (PM) service manuals. Since 2009, oneSOURCE has become a reliable resource for top health care organizations such as Mayo Clinic, Sutter Health and HCA. The Surgical Instruments and Equipment and Tissue/Implants databases enable technicians in sterile processing, infection prevention, decontamination and operating room departments to have access to the most recent cleaning, decontamination and sterilization guidelines necessary to improve patient safety and reduce healthcare-acquired infections. •

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+ PESKY FLY + DUST PARTICLES + UNNECESSARY DOOR OPENINGS

Endless Risks + METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)

+ POSITIONING THE PATIENT

+ STAPHYLOCOCCUS AUREUS

+ BACTERIAL CONTAMINATION

+ HAIR

+ LINT PARTICULATE

+ O.R. TRAFFIC

+ STAPHYLOCOCCUS EPIDERMIDIS

One Solution

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

CE604

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continuing education

Mechanical Ventilation and Weaning By Rebecca E. Oppermann, MS, RCP, RRT he doors swing open and a group of healthcare providers enter, pushing a patient onto your floor. You see your patient lying on the bed intubated, being ventilated via a resuscitation bag. The transport team reports that the patient is sedated and requires mechanical ventilation. As you put the pieces of this puzzle together, you remind yourself of the priorities when taking care of ventilated patients: airway, breathing, and circulation. It immediately becomes your responsibility to safely manage this patient. With an adequate knowledge of modes of mechanical ventilation, nursing care for mechanically ventilated patients, and the weaning process, you are on the road to optimum patient outcomes.

Caring for mechanically ventilated patients is a challenging part of nursing in both acute care and the post-acute care arenas. Promoting patient safety is paramount in caring for mechanically ventilated patients. The nurse must understand current modes and settings of ventilation, exercise-appropriate assessment, ventilation management skills, and safe and successful weaning techniques.1 Mechanical ventilation is initiated in the

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intensive care unit (ICU) for various reasons, including acute respiratory failure or arrest (the most common reason), exacerbation of chronic obstructive pulmonary disease (COPD), coma, neurological diseases and postoperative ventilation support.2,3 During acute respiratory failure, a patient cannot maintain normal ventilation and gas exchange, resulting in a partial pressure of oxygen or PaO2 of less than 60 mmHg, partial pressure of carbon dioxide, or PaCO2 greater than 50 mmHg.4 The primary goals of mechanical ventilation in this situation are to enhance pulmonary gas exchange, decrease work of breathing, increase lung volume, reduce respiratory muscle fatigue, reverse respiratory distress and respiratory failure, improve hypoxemia, and facilitate lung healing.3

The Basics The type of breath, timing of breath delivery, and specific variables controlled during the respiratory cycle determine the mode of mechanical ventilation.5 Straightforward classifications of breath types include mandatory, assisted, spontaneous, or a combination of all three. • Mandatory breaths are completely ventilator-triggered, limited, and cycled (also referred to as ventilator started, sustained, and ended, respectively).5,6 Mandatory ventilation may be used

•

on a person who is sedated or paralyzed during surgery. During an assisted breath, the patient triggers and cycles a breath with support from the ventilator. This mode of ventilation may be used on patients who have

Relias LLC guarantees this educational program free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See Page 41 to learn how to earn CE credit for this module.

Goal and Objectives The goal of this continuing education program is to provide nurses and dietitians with a more indepth understanding of mechanical ventilation and the weaning process for critically ill patients. After studying the information presented here, you will be able to: • Describe current modes and ventilator settings. • Discuss the nursing care of mechanically ventilated patients. • Discuss methods of ventilator weaning to ensure safe patient outcomes.

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continuing education increased oxygen or ventilation demands. The patient will trigger the breath; the mechanical ventilator will do the work and decrease the patient’s work of breathing.7 • Spontaneous breaths are breaths that are triggered, limited, and cycled entirely by the patient. During the respiratory cycle, ventilators are set to measure a particular variable to trigger, limit, and cycle each phase of the respiratory cycle. Ventilator modes use a cycling mechanism and measure volume, pressure, flow, and time to end inspiration.3 Common modes of ventilation are volume control or pressure control.7 For example, if a preset volume is delivered to a patient and inspiration ends, volume is the cycling variable. On the contrary, if a preset pressure is reached and inspiration is terminated, pressure is the cycling variable.

Modes and Settings The patient’s clinical status ultimately determines the appropriate mode and ventilator settings. The goal is to reduce the risk of ventilator-induced lung injury, maintain appropriate oxygenation and carbon dioxide removal, and facilitate safe weaning.8 In many clinical scenarios, initial ventilator settings include the mode as previously described, fraction of inspired oxygen or FiO2 level of 50% to 100%, a respiratory rate of 12 to 18 breaths per minute, and a tidal volume of 6 to 8 mL/kg of ideal body weight (as low as 4cc/kg for certain lung conditions).3 Caution should be used when tidal volumes are set greater than 10 mL/ kg, because an increased risk of cardiac decompensation and ventilator-associated lung injury exists.8,9 Improved outcomes have been noted when the tidal volume is reduced to 6 to 8 mL/kg in patients with acute respiratory distress syndrome or other acute lung injuries. A normal adult’s minute ventilation (tidal volume multiplied by respiratory rate) is 6 to 12 L/minute and it should be titrated to maintain apWWW.ORTODAY.COM

propriate carbon dioxide and pH levels. Ideally, FiO2 levels should be reduced to 0.5 as quickly as possible, because high FiO2 may result in the formation of free radicals and subsequent cellular damage to the lung parenchyma.3,10 Clinicians should pay careful attention to the inspiratory pressure during mechanical ventilation. Inspiratory pressure refers to the pressure required to inflate the lungs and is measured at the end of inspiration. Peak inspiratory pressure is essentially the sum of the pressure required to overcome the elastic properties of the lung and chest wall, along with the pressure required to overcome airway resistance.3 The more restricted or obstructed the lungs are, the higher the PIP. The inspiratory time to expiratory time (I:E ratio) is the ratio of time during the respiratory cycle dedicated to inspiration and expiration. A normal I:E ratio is 1:2, which means the expiratory time is twice as long as the inspiratory time.3 Both inspiratory and expiratory times may be manipulated during mechanical ventilation based on the patient’s respiratory status to improve ventilation and oxygenation. For example, the I:E ratio may be changed to 1:3 or 1:4 to avoid air trapping in the presence of obstructive airway disease or, less frequently, inversed to 2:1 in the presence of poor lung compliance. Positive end-expiratory pressure (PEEP) is applied during the exhalation phase of mechanical ventilation to maintain the patient’s airway pressure above the atmospheric level to resist alveolar collapse and improve hypoxemia and gas exchange.3 PEEP increases functional residual capacity of the lungs. High PEEP (greater than 10 cm H2O) should be used with caution because of the risk of harm from lung overdistension and the possible reduction in cardiac filling. An exhaustive number of ventilator modes exist. The following discussion is intended to provide a general understanding of common ventilator modes and settings. Controlled mechanical ventilation delivers only mandatory breaths to a set

pressure or volume. It is best suited for patients who need complete ventilator support.3 This mode of ventilation is never used on a patient who has any ability to initiate a breath. The circuit is closed and a patient who attempts to initiate a breath would meet resistance. Assist-control ventilation (ACV), a common mode of ventilation, augments spontaneous ventilation by delivering a volume-controlled or pressure-controlled breath at a minimum rate and/or synchronized to a patient’s breath. This mode of ventilation is appropriate for a spontaneously breathing patient who cannot adequately maintain oxygenation and ventilation.3,11 If a patient has a low set breath rate on ACV and receives sedation or narcotics, the breath rate may need to be increased to continue to support adequate oxygenation and ventilation.6 During volume-controlled ventilation, the control variable is volume (unless a peak pressure is reached), and the patient receives a preset tidal volume and respiratory rate.3,11 If pressure-controlled ventilation is used, pressure is the control variable.11 The breath is delivered to a preset pressure and the tidal volume depends on lung compliance and airway resistance.7 Initial settings are often 10 to 20 cm H2O of pressure and titration is necessary to maintain optimal tidal volume. Pressure-Regulated Volume Control is a dual-controlled breath mode that allows for the patient to mimic pressure control and reduce barotrauma, while also guaranteeing a tidal volume. This mode is especially useful in patients who have rapidly changing respiratory mechanics. The ventilator will give a test breath to determine the patient’s compliance and then delivers pressurecontrolled breaths that will achieve the targeted volume. Over time, the compliance is continuously measured, and the pressure-control level is adjusted to maintain the targeted tidal volume that is set by the healthcare professional.3 Synchronized intermittent mandatory DECEMBER 2020 | OR TODAY |

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continuing education ventilation (SIMV) delivers mandatory breaths at a designated rate and tidal volume yet allows spontaneous breathing at any generated tidal volume between ventilator breaths.3 The ventilator synchronizes the patient-ventilator interaction by providing breaths in conjunction with the patient’s spontaneous ventilation. This mode is appropriate for maintaining mechanical ventilation, weaning from the ventilator, improving patient comfort, and reducing the need for sedation.3 Pressure support ventilation (PSV) augments spontaneous ventilation to a preset pressure level without a set rate. During inspiration, the pressure rises quickly to a plateau level and is maintained through the duration of inspiration. Essentially, the patient determines the respiratory rate and tidal volume. Pressure support is often used in conjunction with SIMV to lessen the work of spontaneous ventilation and during ventilatory weaning.3 Pressure control-inverse ratio ventilation simply reverses the traditional I:E ratio of 1:2. The inspiratory time is lengthened and the I:E ratios become 1:1, 2:1, 3:1 or 4:1. The clinician sets the pressure level, respiratory rate, FiO2, PEEP, and sensitivity (or trigger variable). The goal is to keep the lungs open, recruiting more alveoli during inspiration and therefore allowing greater gas exchange. Patients on inverse ratio ventilation require sedation or paralyzation.12 Airway pressure release ventilation (APRV) is designed to allow spontaneous ventilation during any point of the respiratory cycle. APRV is a mode that uses a high continuous positive airway pressure or continuous positive airway pressure (CPAP) with brief breaks in pressure, allowing a lower pressure level to temporarily exist. Ventilation occurs via a pressure-limited and a time-cycled change between the two set pressure levels. CO2 is eliminated by setting the high CPAP level around 15 to 20 cm H2O with a release in pressure to a lower limit, generally 0 to 5 cm H2O.12 APRV uses the design of inversed I:E ratio (as discussed earlier) when the inspiratory

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time is significantly longer than the expiratory time. A release valve allows for spontaneous ventilation during any point in the respiratory cycle. This type of ventilation is desirable for patients requiring high pressures to recruit alveoli during the ventilatory cycle, such as patients with acute respiratory distress syndrome (ARDS). During the longer highpressure period, alveolar recruitment is maintained. During the brief release of pressure, the lung recoils and ventilation is facilitated.13 This type of ventilation reduces the need for sedation or paralytics, because spontaneous breathing can occur during any time in the respiratory cycle. Thus, patient-ventilator synchrony is not necessary.12

Caring for Patients Caring for mechanically ventilated patients requires a systematic strategy to ensure safe and comprehensive assessment and monitoring. The emergency care cycle system of health assessment is appropriate when caring for mechanically ventilated patients. The emergency care cycle is composed of a primary and secondary survey. The primary survey uses the airway, breathing, circulation, disability, and exposure (ABCDE) system of assessment and treatment. The goal is to identify life-threatening situations requiring immediate action.1 Airway assessment is vitally important, because untreated airway obstruction leads to hypoxia and ultimately damage to the brain, heart, and kidneys.12 The security of the artificial airway (i.e., an endotracheal or a tracheostomy tube) must be verified to prevent accidental dislodgment. Swelling of tissues, tension from movement or flexion or extension may cause the airway to move, and the tube may end up too high or too low in the trachea or esophagus. The airway’s patency may be assessed by ensuring air movement and chest rise and fall.1 Unrecognized breathing problems may lead to inadequate blood oxygenation levels and cardiac arrest.14 An assessment of adequate breathing includes chest rise and fall, patient color,

respiratory rate, tidal volume, and pulse oximetry reading. Furthermore, an arterial blood gas provides information about arterial oxygen saturation and ventilation. Inadequate ventilation may cause an increase in carbon dioxide and a decrease in pH (respiratory acidosis).14 Inadequate circulation may be related to heart problems such as myocardial infarction or ischemia, arrhythmias, or heart block secondary to drugs; airway obstruction; apnea; tension pneumothorax; septic shock; or severe blood loss.14 Circulation assessment starts with checking for a pulse and its strength. Further cardiovascular assessment includes heart rate, rhythm, and arterial blood pressure, as hypotension and tachycardia indicate decreased cardiac output.15 Remember that high levels of PEEP may decrease both cardiac filling and cardiac output and result in tachycardia. Altered level of consciousness and reduced urine output also indicate poor cardiac output. An observation of capillary refill shows adequacy of peripheral perfusion. A capillary refill of less than two seconds and cool, mottled, or pale extremities indicate poor peripheral perfusion. An assessment of patient disability involves recognizing changes in level of consciousness; airway, breathing, and circulation problems may all lead to unconsciousness. Finally, exposure involves assessing the patient’s immediate environment, consisting of temperature, adequate analgesia, control of nausea and vomiting and movement of extremities.1,14 The emergency care cycle’s secondary survey uses a head-to-toe approach to assess each body system, which allows complications to be identified early. The Glasgow Coma Scale is widely used for neurological assessment to determine the level of consciousness via arousal, verbal, and physical responses. The Glasgow scale evaluates eye opening, motor response, and verbal response. For nonverbal ventilated patients, nurses, and other healthcare professionals can use communication scoring systems, including letter boards, notes, and mouthing of WWW.ORTODAY.COM

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continuing education words.1 Additional neurological assessment includes pupillary size and reaction, degree of neurological blockage, and sedation scoring. The respiratory system assessment resembles the primary survey in certain ways. Nonetheless, the respiratory system should be reevaluated to ensure the safety of the mechanically ventilated patient. The clinician should reassess and confirm artificial airway placement, security, and cuff status, along with breathing status. Placement may be verified by auscultation of breath sounds, radiological examination (considered the gold standard) or end-tidal carbon dioxide monitoring. Important information that should be documented and used to access artificial airway placement is the depth the endotracheal tube is inserted into the trachea. Endotracheal tubes are inserted, on average, 22 to 26 cm into the trachea. The tube must be secured to reduce the risk of displacement. Commercial securing devices are recommended (some are equipped with a bite block); adhesive or cotton tape may be used.1 Studies support that noncommercial airway holders (e.g., adhesive or cotton tape) exert less force on a patientâ&#x20AC;&#x2122;s face than commercial devices and may not offer the same stability as commercial devices. Airway stability is affected by the type of securing method selected, and many of the commercial securing devices allow for rapid but secure movement of the artificial airway from one side of the mouth to the other. This side-toside movement facilitates oral care and rotation to prevent hospital-acquired pressure ulcer. Any method of securing is acceptable as long as the tube cannot shift independently of head and neck movement.1,(16 Level B) The clinician should regularly assess the cuff to reduce the risk of aspiration from underinflation or mucosal damage from overinflation. Ensuring airway patency also includes assessment and management of lung secretions. Secretions should be suctioned as indicated by patient status and assessed for volume, color, and consistency. Proper suctioning technique reduces the risk of WWW.ORTODAY.COM

hypoxia and atelectasis. Suction catheters should be less than half the internal diameter of the artificial airway. The insertion depth should be 1 cm above the carina before beginning suctioning, and suctioning should last less than 15 seconds.1 Proper humidification of airway gases is essential to reduce the risk of obstruction and damage to respiratory tissue. The clinician must perform a careful physical assessment of breathing, which may reveal inappropriate ventilator settings. Assess for current ventilator settings, including respiratory rate, tidal volume, airway pressures and minute ventilation as well as dyspnea, asynchronous chest and abdominal movement, agitation, and accessory muscle use. Current status, along with trends over time, helps provide a broader picture of respiratory function.1 Monitoring gas exchange via ABG analysis is often considered the gold standard for monitoring oxygen and carbon dioxide levels in the blood. However, noninvasive measures such as oxygen saturation via pulse oximeter are accurate plus or minus 2% for oxygen saturations greater than 90%.17 Mechanical ventilation affects the cardiovascular system. Positive pressure ventilation leads to increased intrathoracic pressure, a decreased preload, and concurrent reduction in cardiac output. The best method for measuring cardiac output is thermodilution via a pulmonary artery catheter. However, less invasive methods such as transesophageal echocardiography, esophageal Doppler, and pulse contour analysis are more cost-effective.1 A desirable method to counteract the decreased preload (and reduction in cardiac output) associated with mechanical ventilation includes maintaining adequate volume status, which may be measured by using central venous pressure. A desirable reading is 10 to 12 mmHg. Continuous assessment of blood pressure, heart rate and rhythm (via continuous electrocardiography), central venous pressure, urine output, and serum electrolytes reveals cardiovascular function.1 Monitoring urine output

provides a method of indirectly measuring cardiac output as neural and hormonal mechanisms (the release of antidiuretic hormone and the renin-angiotensinaldosterone response) are stimulated by a reduction in cardiac output and lead to a reduction in urine output. Urine output of 1-2L/day indicates adequate kidney function.18 Appropriate nutrition helps promote good outcomes for mechanically ventilated patients. Guidelines for nutrition are changing frequently, and it is recommended that each patient be individually assessed for nutritional needs as well as assessed regularly for tolerance.19 Protocols within each hospital should be followed to provide appropriate nutrition to patients based on their individual health, yet often energy requirements are based on 25 kcal-30 kcal/kg/day.19 Some patients are more acutely ill and require different levels of nutrition than others. If mechanically ventilated and receiving enteral nutrition, it is recommended that the bed remain above a 30 degree angle and chlorhexidine mouthwash be used twice daily to reduce the risk of aspiration and ventilator-associated pneumonia.19Level ML Studies have shown that in some circumstances supplementation with parenteral nutrition can be useful in meeting energy needs and minimizing the risk of nosocomial infections and thus decreasing ventilator days.20Level A Increased carbon dioxide production due to overfeeding should be avoided.20 Fluid balance should be maintained, with the addition of water if the patient is on a tube feeding without IV fluids. Hypocaloric feeds are recommended in the obese population, as basing caloric needs on actual weight will mean the delivery of excessive calories and can lead to overfeeding. A caloric intake of 21 kcal/ kg/day along with 2 gm protein/kg ideal body weight or 1.3 to 1.5 gm protein per kg actual body weight is being used successfully.21 Oral or nasogastric feeding tubes are used frequently in clinical practice and feeding protocols are well established. Bowel function assessment indicates GI DECEMBER 2020 | OR TODAY |

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continuing education tract function and includes abdominal discomfort, distention, bowel sounds, and frequency and characteristics of bowel movements. Peptic ulcer disease prophylaxis is recommended as part of the ventilator-associated pneumonia bundle. Common therapy includes the H2receptor antagonists and proton pump inhibitors.21 In addition, clinicians must assess for infection, because ventilated patients are at an increased risk of healthcareacquired infections because of the use of invasive lines and monitors (e.g., urinary catheters and central lines). Aseptic technique is crucial to reduce infection. Measurement of temperature and white blood cell counts are usually used to detect infection. Finally, a thorough assessment of skin integrity reduces the risk of pressure ulcers and ventilator-associated pneumonia while reducing the length of stay and mechanical ventilation.1

Patient Safety The above framework for assessing and monitoring a patient is a major step in promoting patient safety. Nurses must also ensure that emergency equipment is available and working. Emergency equipment includes: • Positive pressure resuscitation bag and facemask • High-flow wall or portable suction • Suction catheters (i.e., Yankauer and endotracheal suction catheters) • Oxygen and intubation equipment Additional safety checks include reviewing safe alarm limits on the ventilator and monitor. Ensure monitoring devices are properly attached and set to patient safety parameters. Ensure the ventilator is connected to an emergency or uninterrupted power supply and functioning appropriately. Check IV infusions.1

Patient Comfort Nurses face the challenge of maintaining patient comfort. The nurse should try

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to create a relaxed and normal environment for the patient and family. Comfort measures include positioning, hygiene, and the management of stressors, which may include pain, invasive lines, or tubes or even the presence of family and healthcare providers. Positioning increases patient comfort, along with improving oxygenation and ventilation by reducing the ventilation/ perfusion mismatch (an inequality of alveolar ventilation and pulmonary capillary blood flow causing hypoxemia). Positions for mechanically ventilated patients include semirecumbent, supine, prone, and lateral decubitus. A semirecumbent position with the head of the bed elevated 35 to 45 degrees reduces the risk of pulmonary aspiration and the incidence of ventilator-associated pneumonia.1,21 Patients’ hygiene needs must be met, including eye and oral care and washing. Eye care includes the use of ointments, gels, normal saline irrigation, and eye drops to reduce the risk of corneal dehydration, abrasions, and infection.1 Oral hygiene may be done using swabs or toothbrushes with commercial mouthwashes, hydrogen peroxide, fluoride, chlorhexidine, or sodium bicarbonate.21 Bathing is an important time for the nurse-patient relationship and provides an opportunity for in-depth assessment. The choice of a complete bath or a partial wash using cleansing agents is based on nurse and patient preference.

Pain and Sedation Pain management and sedation, with regular assessment, are imperative in caring for mechanically ventilated patients. The patient’s report of pain is the most accurate method of pain evaluation, but communication is often a problem for mechanically ventilated patients. Scales such as the visual analogue scale, numeric rating scale and adult nonverbal pain scale can be used to assess pain. In addition, the nurse must assess behavioral and physiological pain indicators. Behavioral indicators of pain include grimacing, frowning, tearing, restlessness, withdrawing, rigidity, stiffness, coughing, gagging, and bucking. Physiological indicators include elevated

or reduced heart rate, respiratory rate and blood pressure, dilated pupils, pallor, and diaphoresis.1 Pain is often managed with IV opioids. Morphine sulfate is preferred for intermittent boluses because of its long duration of action. Fentanyl (Sublimaze®) is used for continuous infusions, because of its rapid onset and short duration of action. The advantage of continuous IV infusions is a steady state of analgesia. The nurse should assess and monitor sedation. The nurse can use the Ramsay Sedation Scale, Glasgow Coma Scale, Riker Sedation-Agitation Scale, Richmond Agitation-Sedation Scale, Minnesota Sedation Assessment Tool or Motor Activity Assessment Scale to monitor level of sedation; no one scale has been proven superior.1,22 Because continuous sedation often increases the time patients are mechanically ventilated, clinicians should use guidelines and protocols to improve patient outcomes.1 Medications such as midazolam (Versed®), diazepam (Valium®), lorazepam (Ativan®), haloperidol (Haldol®), and propofol (Diprivan®) have been used to provide amnesia, reduce anxiety, improve tolerance of mechanical ventilation, control delirium, and facilitate the sleepwake cycles. The sedative agent should be determined on an individual basis. Midazolam and diazepam are typically instituted for quick sedation because of their rapid onset. Propofol is another option for rapid sedation, but it requires monitoring of triglyceride levels. Lorazepam is typically for long-term sedation.22 Evidencebased ventilator care bundles recommend daily interruption of sedation and assessment of readiness to wean to reduce the risk of ventilator-associated pneumonia and reduce intubation time.21,23

Neuromuscular Blockade Neuromuscular blocking agents (NMBAs) use may be required for patients with ARDS to improve oxygenation, inflammation, and mortality.24 Common NMBAs used include vecuronium (Norcuron®), pancuronium (Pavulon®), cisatracurium (Nimbex®), and atracurium (Tracrium®). It is important for WWW.ORTODAY.COM

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continuing education nurses to know that NBMAs do not have any analgesic or anxiolytic properties and treatment for pain and sedation are used in conjunction with NMBAs. Proper dosing of NMBAs includes titration based on patient’s response to train-of-four, peripheral nerve stimulation. A peripheral nerve stimulator is attached to a patient’s ulnar nerve area of the arm and is programmed to release four small electrical stimuli in sequence. Twitching of muscles in the hand in response to the ulnar nerve stimulation identifies the approximate percent of neuro-receptors blocked by the NMBA. The goal of NMBAs is a response of one to three twitches depending on the level of muscular blockade intended.25 Nursing care of patients receiving NMBAs requires a heightened awareness to the development of complications that include corneal abrasions, muscle breakdown, venous thromboembolism, and hospital-acquired pressure ulcers. Use of eye lubricants, frequent turning and positioning, range of motion exercises, and skin assessments are basic nursing interventions to prevent complications. The use of heparin for venous thromboembolism prevention along with sequential compression devices are indicated for patients receiving NMBAs and as part of the ventilator-associated pneumonia bundle.21

Weaning Removal of the endotracheal tube when it is no longer necessary is referred to as extubation. However, before extubation, ventilatory weaning must take place. Weaning is the process of reducing ventilatory support and increasing spontaneous ventilation. The goal of weaning is to avoid overventilation or underventilation without causing fatigue.26 (Level ML) The weaning process should begin shortly after the initiation of ventilatory support. Because the process is complex, good clinical judgment is paramount to successful and safe weaning. A team of healthcare providers performs ventilatory weaning using various protocols, but a few key variables are manipulated. Some of these variables include varying mandaWWW.ORTODAY.COM

tory breaths, altering FiO2, and altering level of pressure support.27 Before extubation, emergency equipment should be available and checked. Timing of extubation is important. Trained airway management providers (i.e., physician, anesthesiologist, or CRNA) should be available to help with problems. After extubation, a one-to-one nurse/patient ratio is appropriate for monitoring.26Level ML The nurse should thoroughly explain extubation to the patient and family. A healthcare facility’s policy often determines criteria for extubation. However, if no standardized guidelines are available, the decision to extubate should be based on patient assessment, good communication with the healthcare team, and sound clinical judgment.17 A broad system-based set of criteria or the use of a weaning assessment tool are accepted in practice to ensure a patient is ready for extubation.14,26 Level ML,28(Level B) Criteria include: • An awake, alert, and cooperative patient • An improving condition from the problem that required mechanical ventilation • Adequate cough and swallow reflexes • Minimal secretions • Maintenance of adequate spontaneous ventilation and gas exchange • Normal respiratory rate and pattern • ABG within patient’s normal limits on minimal oxygen • Hemodynamically stable heart rate, cardiac output, and systolic blood pressure of 100 mmHg • Minimal inotropic support • No major metabolic disturbances, normal electrolyte levels, acid-base balance • Reversal of muscle relaxants • Adequate respiratory muscle strength, spontaneous tidal volume greater than 5 mL/kg • Sedation stopped • Pain controlled Before extubation, the patient should be placed in a Fowler’s or reverse

Trendelenburg position. Several techniques are used for extubation, including the trailing suction catheter technique and positive pressure breath technique. The trailing suction catheter technique involves placing a suction catheter through the endotracheal tube (ETT) into the trachea. Suction is applied, the cuff is deflated, and the ETT and suction are removed. The advantage of this technique is the removal of chest and pharynx secretions. The disadvantages are the risk of hypoxia and atelectasis. The positive pressure technique involves using a rebreathing bag to deliver a positive pressure breath with 100% oxygen and simultaneously deflating the cuff, then removing the ETT.26Level ML The goal is for the patient to cough immediately post-extubation to clear the airway and improve oxygenation. The nurse must closely monitor patients after extubation. Respiratory observation includes inspection of work of breathing, rate and rhythm of respirations, use of accessory muscles, chest expansion and symmetry, obstructive breathing pattern and respiratory distress, as well as auscultation of breath sounds in all lung zones for evidence of retained secretions and bronchospasm. Further assessment consists of monitoring for airway obstruction and impaired oxygenation, evidenced by stridor and a poor pulse oximeter reading. (Stridor is recognizable by a harsh “crowing” sound.) Cardiovascular assessment of blood pressure, heart rate, and peripheral skin temperature may indicate a stress response resulting from difficulty in breathing. Neurological evaluation may reveal carbon dioxide retention from inadequate ventilation; as mentioned, an ABG is necessary for confirmation.26 Level ML Post-extubation airway complications may be life-threatening and require immediate intervention. Common complications include laryngospasm, desaturation, coughing and airway obstruction. Airway problems may be treated with high concentrations of oxygen, jaw thrusts, placement of an oral or nasal airway, or reintubation.14 DECEMBER 2020 | OR TODAY |

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continuing education Conclusion Caring for mechanically ventilated patients is an integral and challenging part of nursing in hospital settings, long-term acute care hospitals, and skilled nursing facilities. Paramount to the safety of the mechanically ventilated patient is the nurse’s ability to understand current modes and settings of ventilation, develop appropriate assessment and management skills, and understand safe and successful weaning techniques.1 With a deeper knowledge of ventilator modes and settings, appropriate care for mechanically ventilated patients and safe ventilatory weaning and extubation practices, nurses, dietitians, and other healthcare professionals will be better able to provide excellent care to mechanically ventilated patients, thus facilitating optimal outcomes. Relias LLC guarantees this educational activity is free from bias.

Respiratory Care. 11th ed. St. Louis, MO: Elsevier; 2017:1079-1110. 4. Aboussouan L. Respiratory Failure and the Need for Ventilatory Support. In: Kacmarek RM, Stoller JK, Heuer AJ, eds. Egan’s Fundamentals of Respiratory Care. 11th ed. St. Louis, MO: Elsevier; 2017:973-986. 5. Chatburn RC, El-Khatib M, Mireles-Cabodevila E. A taxonomy for mechanical ventilation: 10 fundamental maxims. Resp Care. 2014;59(11): 1747-1763. doi: 10.4187/respcare.03057. 6. Tobin MJ. Principles and Practice of Mechanical Ventilation. 3rd ed. New York, NY: McGrawHill Inc.; 2013. 7. Chatburn R, Volsko T. Mechanical Ventilators: Classification and Principles of Operation In: Hess DR, MacIntyre NR, Galvin WF, Mishoe SC, eds Respiratory Care: Principles and Practice. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2016: 462-492. 8. Stephens RS, Shah AS, Whitman GJR. Lung Injury and Acute Respiratory Distress Syndrome After Cardiac Surgery. Ann Thorac Surg. 2013;95(3):1122-1129. 9. Shorofsky M, Jayaraman D, Lellouche F, Husa R, Lipes J. Mechanical ventilation with high tidal volume and associated mortality in the cardiac intensive care unit. Acute Cardiac Care. 2014:16(1):9-14. doi: 10.3109/17482941.2013.869345.

EDITOR’S NOTE: Holly Franson, MSN, CRNA, and Nicolette C. Mininni, MEd, BSN, RN, CCRN, an advanced clinical education specialist for critical care at the University of Pittsburgh Medical Center, UPMC Shadyside, in Pittsburgh, were previous authors of this educational activity. They haven’t had an opportunity to influence the content of this current version.

10. Bein T, Grasso S, Moerer O, et al. The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia. Intensive Care Med. 2016;42:699-711.

REBECCA OPPERMANN MS, RRT, RCP, NRP, is a lecturer at the School of Health and Rehabilitation Sciences, The Ohio State University, and a Registered Respiratory Therapist for Riverside Methodist Hospital.

13. Andrews P, Habashi NM. Airway Pressure Release Ventilation. Curr Probl Surg. 2013;(50):462470. doi:10.1067/j.cpsurg.2013.08.010.

References

15. Rodriguez N. The Cardiovascular System. In: Kacmarek RM, Stoller JK, Heuer AJ, eds. Egan’s Fundamentals of Respiratory Care. 11th ed. St. Louis, MO: Elsevier; 2017:209-225.

1. Couchman BA, Wetzig SM, Coyer FM, Wheeler MK. Nursing care of the mechanically ventilated patient: what does evidence say? Part one. Intensive Crit Care Nurs. 2007;23(1):4-14. doi: 10.1016/j.iccn.2006.08.005. 2. Burns SM. Mechanical ventilation and weaning. In: Advanced Critical Care Nursing. St. Louis, Missouri: Saunders Elsevier; 2nd edition. 2017.:183-201 3. Kacmarek R. Initiating and Adjusting Invasive Ventilatory Support. In: Kacmarek RM, Stoller JK, Heuer AJ, eds. Egan’s Fundamentals of

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11. Bristle T, Collins S, Hewer I, Hollifield K. Anesthesia and critical care ventilator modes: past, present, and future. AANA J. 2014:82(5):387400. 12. Burns SM. Pressure modes of mechanical ventilation: the good, the bad, and the ugly. AACN Adv Crit Care. 2008;19(4):399-411. doi: 10.1097/01.AACN.0000340721.

14. Younker J. Care of the intubated patient in the PACU: the ‘ABCDE’ approach. J Periop Pract. 2008;18(3):116-120. DOI:10.1177/175045890801800304

16. Fisher DF, Chenelle CT, Marchese AD, Kratohvil JP, Kacmarek RM. Comparison of commercial and noncommercial endotracheal tube-securing devices. Resp Care. 2014:59(9):1315-1324. doi: 10.4187/respcare.02951.

ogy. In: Hess DR, MacIntyre NR, Galvin WF, Mishoe SC, eds Respiratory Care: Principles and Practice. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2016: 1182-1204. 19. McClave S, Taylor B, Martindale R, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) JPEN J Parenter Enteral Nutr. 2016; 40(2):159-211. doi: 10.1177/0148607115621863. 20. Heidegger C, Berger M, Graf S, et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. The Lancet. 2013; 381(9864)385-393. doi: 10.1016/S01406736(12)61351-8. 21. Munro N, Ruggiero M. Ventilator associated pneumonia bundle: reconstruction for best care. AACN Adv Crit Care. 2014:25(2):163-175. doi: 10.1097/NCI.0000000000000019. 22. Fuchs EM, VonRueden K. Sedation management in the mechanically ventilated critically ill patient. AACN Adv Crit Care. 2008;19(4):421432. doi: 10.1097/01.AACN.0000340723.802-80. ff. 23. Keyt H, Faverio P, Restrepo M. Prevention of ventilator-associated pneumonia in the intensive care unit: A review of the clinically relevant recent advancements. Indian J Med Res. 2014; 139(6):814-821. 24. Frazee EN, Personett HA, Bauer SR, et al. Intensive care nurses’ knowledge about use of neuromuscular blocking agents in patients with respiratory failure. Am J Crit Care. 2015:24(5):431-439. doi: 10.4037/ajcc2015397. 25. D’Arcy Y, Burns SM. Pain, sedation, and neuromuscular blockade management. In: Burns SM, ed. AACN Essentials of Critical Care Nursing. 3rd ed. New York: McGraw Hill; 2014: 159-181. 26. AARC Guideline: Removal of the Endotracheal Tube. American Association for Respiratory Care Clinical Practice Guidelines website. https://www.aarc.org/wp-content/uploads/2014/08/removal_of_endotracheal_tube. pdf. Published January 2007. Accessed April 5, 2018. 27. Pattison N, Watson J. Ventilatory weaning: a case study of protracted weaning. Nurs Crit Care. 2009;14(2):75-85. doi: 10.1111/j.14785153.2008.00322.x. 28. Burns SM, Fisher C, Tribble SE, et al. The relationship of 26 clinical factors to weaning outcomes. Am J Crit Care. 2012:21(1):52-59. doi: 10.4037/ajcc2012425.

17. Jubran A. Pulse oximetry. Crit Care. 2015;19:272. doi: 10.1186/s13054-015-0984-8. 18. Sergakis G, Dunlevy C, Varekojis S. Cardiovascular, Renal, and Neural Anatomy and Physiol-

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CE604

How to Earn Continuing Education Credit Clinical Vignette Julie Reynolds, age 72, has been battling pancreatic cancer for many months. Julie has not been able to wean off of the ventilator since her Whipple procedure five weeks ago. She weighs 121 pounds and is 5 feet 4 inches tall. She is very edematous from multiple fluid resuscitations, low albumin levels from fluid overload and prolonged inadequate nutrition, and immobility. Her physical assessment indicates a blood pressure of 89/52 mmHg, heart rate 102 beats per minute and oxygen saturation 93%. Julie is on a ventilator with settings of FiO2 50%, tidal volume 800 mL, respiratory rate 12, I:E ratio 1:2 and PEEP 10.

1. Suddenly you notice Julie’s PIP is 45 cm H2O. What lung properties may cause an elevated PIP? a. R esolution of airway c. Poor oxygenation trapping d. R estricted and obb. Improved lung comstructed lungs pliance 2. What is an appropriate tidal volume for Julie? a. 500 to 600 mL c. 340 to 450 mL b. 450 to 550 mL d. 250 to 350 mL 3. What are the potential adverse effects Julie may experience because of her elevated PIP? a. P neumothorax and c. S troke and pneumoreduced cardiac output thorax b. Pneumomediastinum d. E levated cardiac outand hemorrhage put and hemothorax 4. A reduction in tidal volume and reduction in PEEP do not reduce Julie’s PIP, so the healthcare team decides to change the mode of ventilation to pressure control. What would be an appropriate initial pressure to set for Julie? a. 8 cm H2O c. 28 cm H2O b. 18 cm H2O d. 42 cm H2O

Clinical VignettE ANSWERS 1. Answer: D, The higher the PIP, the more restricted or obstructed the lungs have become. 2. Answer: C, Typical tidal volumes are 6 to 8 mL/kg. 3. Answer: A, Adverse outcomes from high PIP include volutrauma, reduced cardiac output, and barotrauma (i.e., pneumothorax and pneumomediastinum). 4. Answer: B, Appropriate initial settings for pressure control ventilation are 10 to 20 cm H2O. WWW.ORTODAY.COM

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 9/6/2022 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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YEAR OF THE

NURSE & MIDWIFE BY DON SADLER he World Health Organization (WHO) designated 2020 as “The Year of the Nurse and the Midwife.” This year was chosen to recognize the 200th anniversary of the birth of Florence Nightingale, a visionary nurse and leader from the 19th century who is widely regarded as the founder of modern nursing.

It’s fitting that 2020 is designated as The Year of the Nurse when you consider the courageous work of nurses done this year in the face of the COVID-19 pandemic. “In this Year of the Nurse and the Midwife, the eyes of the world are on our profession in a way that we could not have anticipated,” says Annette Kennedy, the president of the International Council of Nurses. “Nurses are in the spotlight, and all around the planet this tragic pandemic is revealing the irreplaceable work of nursing for all to see.”

NIGHTINGALE’S IMPACT ON NURSING Nightingale was an upper-class British woman who led a group of volunteer female nurses to the Crimea in 1854 to help care for British soldiers who were wounded during the fighting. The conditions were brutal as medicines were in short supply and hygiene was being neglected, resulting in mass infections and death. Many more soldiers were dying from illnesses caused

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by these conditions than from battle wounds themselves. It’s estimated that Nightingale’s work, including implementation of basic hygiene practices like hand washing, was instrumental in reducing the death rate among wounded British soldiers in the Crimea from 42% to just 2%. Nightingale earned the nickname “The Lady with the Lamp” while serving in the Crimea when a report in The Times described her as a “ministering angel … with a little lamp in her hand, making her solitary rounds” among the wounded. When she returned to England after the war, Nightingale established nurse education programs in British hospitals based on what she learned out in the field. The programs were organized around Nightingale’s beliefs and ideas about how nurses should be educated, which came to be known as “Nightingale Principles.” The Nightingale Training School was established in 1860 and the first Nightingaletrained nurses started work five

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years later at the Liverpool Workhouse Infirmary, which is now called the Florence Nightingale School of Nursing and Midwifery. In 1859, Nightingale wrote “Notes on Nursing,” which is still considered a classic introduction to the nursing profession.

NURSING FROM THE CIVIL WAR TO TODAY

“

Nurses are in the spotlight, and all around the planet this tragic pandemic is revealing the irreplaceable work of nursing for all to see. – Annette Kennedy, the president of the International Council of Nurses

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The outbreak of the Civil War in the United States in 1861 created an urgent need for capable nurses to help care for the tens of thousands of sick and wounded soldiers on the battlefield. A total of approximately 20,000 men and women served as battlefield nurses during the Civil War in both the North and the South. After the war, nurse training programs began to emerge, including a six-month program at the Women’s Hospital of Philadelphia that graduated its first class in 1869. In 1873, three nurse education programs that were based on the Nightingale Principles were established – this is generally considered to be the beginning of professional nurse education in the U.S. The success of these “Nightingale schools,” as they were known, led to the establishment of many more nurse training programs in the U.S. throughout the late 19th century. By 1900, between 400 and 800 of them were in operation. Their success and popularity resulted in a pattern of hospital-based nurse education that was common until the mid-20th century. Meanwhile, the first major professional nursing associations were formed in the 1890s: the American Society of Superintendents of Training Schools for Nurses, later known as the National League of Nursing Education; and the Associated Alumnae of the United States, later known as the American Nurses Association. The vital contributions of nearly 80,000 nurses were widely acknowledged as critical to the Allied forces’ victory

in World War II. Many of these nurses transitioned into the modern health care system that emerged in the U.S. after the war, though severe nursing shortages were common as the work was extremely demanding and the pay was low. By the mid-20th century, nursing largely began to eliminate the racial and gender segregation that was common. This opened up equal educational, professional and employment opportunities for more nurses. Specialty types of advanced practice nursing also started to emerge in the 1960s, including perioperative nursing.

RECOGNIZING TOP PERIOPERATIVE NURSES To celebrate The Year of the Nurse and the Midwife, OR Today has received submissions throughout this year recognizing perioperative nurses for their excellent practice and devotion to nursing. Here are a few of the perioperative nurses who were recognized by OR Today readers: •L isa Van Deer, RN, CNOR, Surgery Manager, VanDiest Medical Center Lisa was recognized by her coworker Robin Meyer, who stated: “Lisa was by my side the entire time we were heavy in COVID-19. She came to work every day with a smile on her face and kept all of the instrumentation clean and sterilized. Lisa also came up with a plan to get the N-95 masks re-sterilized to keep all the staff safe until supplies came in.” • Anne Mørk, MHCDS, MS, RN, Director of Surgical Services, UW Health-University Hospital Anne was nominated by her coworker Ann White, who stated: “COVID-19 has shattered the care of delivery as we know it, yet Anne remains positive and continues the relentless journey to move UW Health forward during the recovery phase. She works long days and her performance never wavers. Anne is a superb nursing role model and mentor and a natural leader.”

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•N ancy Walters, RN, BSN, CNOR, CIC, Christus Imperial Calcasieu Surgical Center Nancy was nominated by coworker Sherry White, who stated: “Nancy was my OR supervisor in the beginning of my career and an awesome mentor who inspired everyone in her department to become the best OR nurse they could be. She never hesitated to share her knowledge of the OR and encourage and defend her staff in times of conflict.” • Vivian Watson, consultant, ORDx+Rx: Solutions for Surgical Safety (retired) Vivian was nominated by Sharon McNamara, who stated: “Vivian’s name brings feelings of love and compassion for patients and colleagues. She served on the AORN Board and was AORN’s only Ombudsman for more than 10 years. Vivian comes from a sharecropper’s daughter background, was born with a cleft lip has overcome much to be a nurse.” • Amy Lammers, RN, Promedica Bay Park Hospital Amy was nominated by an anonymous coworker, who stated: “I’m nominating

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Amy because of her hard work and dedication to treating patients infected with the coronavirus. She has been an RN for 25 years and is currently working in an ICU of a hospital that was only treating patients with COVID-19 during the peak of the pandemic. Amy sees her role in defeating this virus as crucial to the safety of her family, friends and everyone in the world.” •S ue Olson, Interim Assistant Nurse Manager, University of Iowa Hospitals and Clinics Sue was nominated by Alicia Rock-Cleppe, who stated: “Sue has always been the nurse who inspires me the most. She is patient and kind, extremely knowledgeable and the true embodiment of an excellent OR nurse. Thank you, Sue, for inspiring me to be a better nurse and a better person.” OR Today joins in congratulating each of these outstanding nurses – and all the perioperative nurses who demonstrate their devotion to the profession each and every day.

DECEMBER 2020 | OR TODAY |

SPOTLIGHT ON:

Lisa VanDeer RN, CNOR By Matt Skoufalos

nyone who’s ever understood the wisdom of “home is where the heart is” would be hard-pressed to find someone who’s lived the truth of that expression as fully as Lisa VanDeer, RN, CNOR. Training for her career and doing the job itself in her hometown of Webster City, Iowa, has given this 14-year nurse a sense of familiarity with the community and its inhabitants that helps her to connect deeply with her work. Working as a nurse “is what I’ve always wanted to do,” VanDeer said. “I can remember being younger and thinking, ‘When I’m done with high school, I’m going to nursing school,’” she said. “I love taking care of people. They usually go home happy.” After high school, VanDeer completed her nursing certification at Iowa Central Community College in Webster City, and then was hired on at a 25-bed community hospital, Van Diest Medical Center, just two minutes away. “One of the reasons I stay is it’s right in my hometown,” VanDeer said. “It’s where I have lived my whole life. I like being able to look at the patient list and see who’s there; it’s comforting for them to be able to see a friendly face.” “It’s the right fit because it’s a smaller place,” she said. “I wouldn’t want to work in a big hospital where you’re just another employee to some people. It’s very homey and family-friendly.” That same family atmosphere permeates the surgical department at Van Diest, where Surgery Manager Robin Meyer encouraged members of the nursing staff to earn their Certified Perioperative Nurse (CNOR) credentials, and then supported them through the studying and

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Lisa VanDeer enjoys serving her hometown as a nurse.

testing process required to achieve them. The boost to her education (and career) confirmed for VanDeer that she was in the right place with the right people; an environment in which she’s thrived throughout her nursing career. “Since I’ve been here so long, I do a lot of orientation with new employees, whether it’s the computer system, or how to circulate, or ordering supplies and making sure they have the right stuff for the cases,” VanDeer said. “That’s the kind of leadership I like to do; that’s fun for me and that’s important for me.” VanDeer also loves working in surgery, where she also oversees sterile processing of equipment, “and there’s little change in the routine,” she said – at least, there was, until this spring, when the novel coronavirus (COVID-19) pandemic swept across the globe. “I take care of instruments for the clinic, the ER, our department and our satellite clinics,” VanDeer said. “I had all of my normal stuff to do besides doing the pain injections and equipment processing.” “Now I’ve got something different every day,” she said. “It keeps it interesting.” When the pandemic hit Iowa in March, health care workers had known it was coming, but were still surprised by how hard it hit. As happened in many parts of the country, surgical departments at Van Diest were limited to taking on emergency cases only. Staffers were offered options of furloughs or unemployment; if nurses wanted hours, they were allowed to work the med/surg floor, but had less say over their schedules. The Monday-through-Friday WWW.ORTODAY.COM

day shift pivoted to a 24-hour operation, which reflected a considerable change. VanDeer’s unit also received overflow calls from the hospital’s affiliated specialty clinics, which were completely shut down; in short, VanDeer and Meyer found themselves doing the work of a seven-person staff. Meyer remembers VanDeer as being “by my side the entire time we were heavy in COVID-19.” “It was really hard to come to work every day,” Meyer said. “It was going to be me and Lisa, and that was all it was going to be, no matter what they threw at us. Lisa came to work every day with a smile on her face, and kept all of the instrumentation in the hospital cleaned and sterilized.” That latter contribution was especially important, as sterile equipment was in short supply during the pandemic. Given a global dearth of N95 masks, VanDeer worked out a way to reprocess them using the Sterrad plasma sterilization unit in her department and an FDA-certified cleaning plan. Thanks to her efforts, health care workers in her department and the affiliated clinics could get three uses out of a single face covering – once out of the package and twice more after reprocessing – which helped them get through the worst of the shortage in personal protective equipment (PPE). By mid-June, normal operations ramped up slowly; employees started to return, and eventually, new patients were scheduled again. Educating them about safety measures in the facility did take some doing as well as an abundance of caution. Neighboring counties have had quite a few COVID-19 cases, in part due to seasonal workers in Iowa’s heavy agrarian communities, and in part because of refusals to wear protective face coverings in a state without a mandatory mask law. Hamilton County, where Webster City is located, has only seen about 400 COVID-19 cases, but Story and Webster counties’ cases number in the thousands. For many patients, it was a surprise that they had to wear face coverings on the hospital premises. Thankfully, and in no small part because of tight, in-house controls, as well as to Meyer’s and VanDeer’s efforts, the hospital hasn’t faced any significant COVID-19 outbreaks during its return to normal operations. For VanDeer, it’s part and parcel of a career that is implicitly “a continuous, everyday learning process.” “A couple years ago, did I ever think I would be in charge of all the sterile processing?” VanDeer said. “No, but I’ve been doing that for a year, and I love it. Every day is a little different for me. I still get to scrub for surgeries; I still get to circulate. In our department, I get to do it all. It’s a win-win for me.” DECEMBER 2020 | OR TODAY |

OUT OF THE OR fitness

Strong Legs

for a Strong Back By Miguel J. Ortiz hen it comes to lifting

W heavy items, especially off the floor, we often hear “make sure to lift with your legs.” Lifting with your legs will absolutely help prevent back pain and provide a better lift. So, I need to keep lifting with my legs and keep my legs strong in order to have a strong core and back. But what if you’re already experiencing pain? How do you begin to strengthen your legs if our back is already hurting? Let’s take a look at three tips that will promote success when starting a more vigorous leg routine, including squats. First, we want to make sure that we have started to loosen up the legs and back. I cannot emphasize how important it is to stretch and loosen up the back before a workout. If you are looking to do leg exercises and you do not stretch or move the body to get loose then you’re asking for pain. Existing back pain may require doing stretches while lying on the floor. This will make stretching easier on your back. Next, make sure you’re not exceeding ranges of motion that

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may cause compensation on the knee joint, the hip, etc. This can affect the back. After you have stretched out and relieved some general pain, make sure that you are able to perform the movements properly with just your body weight. Make sure you’re doing it correctly or using the proper range of motion for you. Second, be mindful of machines. If your using a machine correctly you will naturally minimize your risk of injury. However incorrect use could just be aggravating preexisting pain. Let’s take a look at the leg press machine. A lot of people won’t do squats because they say it will hurt their back. Yet, they will jump right onto a leg press machine. It makes sense because when squatting your back is loaded and that means proper form is extremely vital. Add to the formula that the majority of people don’t have proper form. Instead they sit on a leg press machine and it completely takes the core out of the workout because the back is supported. People are only working their legs. You may ask, “Where is the problem?” When in life are you going to lift something with your legs where your back isn’t involved? The answer is simple, you won’t. If your leg

strength is only good when your back is supported then are your legs really that strong? Last, but not least, my third tip is to take your ego out of the equation. If you’re in pain and refuse to slow down your squats, take the weight down, correct any imbalances or stretch to improve your range of motion then problems will continue and can become worse. In order for your back to work properly during squats, it’s important to realize that it’s not about how much you lift. It’s about how you lift it. You are not going to lose as much strength as you think. When learning to do squats and other leg exercises (like lunges and deadlifts) properly, it will ensure a straight spine, solid core activation and keep the back strong. Enjoy your workouts and don’t ever be afraid to relearn a movement in order to move with better efficiency. Miguel J. Ortiz is a personal trainer in Atlanta, Georgia. He is a member of the National Personal Trainer Institute and a Certified Nutritional Consultant with more than a decade of professional experience. He can be found on Instagram at @migueljortiz.

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OUT OF THE OR health

Study Shows Decline in Awareness, Treatment and Control of High Blood Pressure fter nearly 15 years on an upward trend, awareness among Americans about high blood pressure and how to control and treat it is now on the decline, according to a new study. Even with the help of blood pressure medications, some groups, including older adults, are less likely than they were in earlier years to adequately control their blood pressure, the research found.

The study, funded by the National Heart, Lung and Blood Institute (NHLBI), part of the National Institutes of Health, appeared online on September 9 in JAMA. The authors say the trend could make longstanding efforts to fight heart disease and stroke – leading causes of death in the United States – even more challenging. High blood pressure, also called hypertension, is a major risk factor for heart disease. According to the Centers for Disease Control and Prevention (CDC), nearly 108 million Americans have hypertension, with a blood pressure reading of 130/80 millimeters of mercury (mm Hg) or higher or are taking medication for their blood pressure, but only 27 million are considered to have their blood pressure under control, despite it being a condition that can be managed.

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“Reversing this decline is important because we don’t want to lose public health achievements built over prior decades,” said Lawrence Fine, M.D., chief of the clinical applications and prevention branch at NHLBI and a study coauthor. “It is a challenge for the scientific community to investigate the causes of this unexpected downward trend but developing more effective strategies to reverse and substantially improve blood pressure control is critical for the health of many Americans.” The study included 18,262 U.S. adults age 18 and older, with high blood pressure. The definition of hypertension at the time of the study was defined by a blood pressure reading of 140/90 mm Hg or higher or by treating the condition with blood pressure medications. Participants with a blood pressure reading of less than 140/90 mm Hg were categorized as having controlled blood pressure. With data from the National Health and Nutrition Examination Survey (NHANES) taken between1999 and 2018, the study authors looked at 20year trends in high blood pressure awareness and treatment and blood pressure control. The CDC’s National Center for Health Statistics conducts NHANES. At the beginning of the survey, participants had their blood pressure measured three times, then averaged. Participants

answered yes or no when asked if their doctors told them they had high blood pressure and if they currently took prescribed medication for high blood pressure. The authors found that in 1999-2000, just 70% of participants showed an awareness of their condition. That number increased steadily to 85% in 20132014 but declined to 77% in 2017-2018. Of those “aware” adults, the number who also were taking blood pressure medications remained relatively consistent – 85% in 1999-2000, 89% in 2013-2014, and 88% in 2017-2018. “The reversal in hypertension awareness is a real set back in the fight to reduce heart disease and stroke,” said Paul Muntner, Ph.D., the lead study author who also is professor and associate dean for research in the school of public health at the University of Alabama at Birmingham. “While lifestyle factors are big contributors to hypertension, awareness and appropriate treatment are key to lowering blood pressure and keeping it in a healthy range to greatly reduce the risk for heart disease and stroke.” Of all adults with high blood pressure, the number who managed to control their condition increased from 32% in 1999-2000 to 54% in 2013-2014, but then declined to 44% in 2017-2018. Of those adults with controlled blood presWWW.ORTODAY.COM

sure, the number taking blood pressure medication increased from 53% in 1999-2000 to 72% in 2013-2014, then declined to 65% in 2017-2018. These observations, Muntner said, underscore the importance of continuity of care, including having a usual source of care and regularly scheduled health care visits that could increase high blood pressure awareness and treatment and blood pressure control among adults. Between 2015 to 2018, adults age 60 and older, as well as Black Americans as a group, were less likely than adults ages 18 to 44 and whites as a group to have controlled blood pressure. But participants with Medicaid as their health insurance were more likely to have their blood pressure under control than those without health insurance. There are several effective approaches to combat high blood pressure. “Educating patients and providers on blood pressure goals, adding effective blood pressure medications when lifestyle changes aren’t enough, and reducing barriers to achieve high medication adherence in a variety of clinical practice settings are just a few strategies that may facilitate increases in blood pressure control rates and reduce health disparities we identified in the current study,” said Muntner. NHLBI is the global leader in conducting and supporting research in heart, lung, and blood diseases and sleep disorders that advances scientific knowledge, improves public health and saves lives.

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OUT OF THE OR EQ factor

How To Do Away With Resentment By daniel bobinski

id you know that one of the best choices in life – even at work – is gratitude? Being thankful is like a magical elixir that erases tension, and the cool thing is we can choose it. Conversely, one of the more damaging choices we can make is resentment. Simmering with jealousy or bitterness creates barriers that inhibit teamwork and productivity.

When I teach on this, I always start by asking people to identify situations in which they have bitterness or resentment. Yes, that means getting brutally honest with oneself, and yes, it means getting a little vulnerable. To help remove barriers to that, I always offer my own retrospection first. Specifically, I realized I often became envious and resentful when I wanted something but someone else got it instead. As an example, years ago I used to look through the Craigslist “free” section for something I might be able to use. Often those ads say something like, “It’s in the front yard, we’ll remove this ad once it’s gone.” If I wanted an item, I’d hurry out to my car and zip over to pick it up. One day I saw that someone was WWW.ORTODAY.COM

giving away their bicycles. I had a friend who was in the market for bikes, so I got in my car and hurried over to pick them up. I was anxious the entire way, hoping to surprise my friend with this “find.” As fate would have it, when I got to the address, someone was loading the bikes into his truck. My envy was palpable. My body was full of angst. “If only I hadn’t hit those red lights!” “If only I’d checked the Craigslist page 10 minutes earlier!” Later, when contemplating those thoughts and feelings, I realized that my envy was a choice. And, remembering that my behaviors affect my thoughts, and my thoughts affect my feelings, I decided I needed to choose a different behavior. I chose to replace the bitterness with gratefulness, and to reinforce that, I also chose to celebrate. And so, the next time I left my house to pick up a “free” item, I first chose to be thankful and even celebratory. No matter what the outcome of my trip, I decided to celebrate that someone (maybe me, maybe someone else) got a cool item at no cost. After being celebratory and grateful no matter the outcome, I can report that instead of angst,

those choices put me in a great mood, even if an item was already gone. Key point to remember: Both resentment and gratefulness are choices. How does this apply to our work? Resentment, envy or bitterness can occur if you get passed over for a promotion. It can happen if someone else gets that sweet assignment you were hoping for. Whether an injustice is real or perceived, resentment brings angst and division. And it’s a choice. But you can choose differently. If you find yourself feeling bitter about something, why not look for ways to have gratitude?

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 at 208-375-7606.

DECEMBER 2020 | OR TODAY |

OUT OF THE OR nutrition

Sulfur: The Necessary Nutrient You Are Not Thinking About By Kirsten Serrano uring the holidays, it’s more important than ever to be intentional about your nutrition. Partake in some holiday eats if that works for you but be sure to get plenty fresh produce too. I am a huge proponent of eating seasonally. Depending on where you live, you may be thinking that there is not much on offer right now. Despite the weather, there are many winter vegetables in season. That includes the brassica family of vegetables. Brassicas include cabbage, broccoli, Brussels sprout, cauliflower, kohlrabi, kale, bok choy and more. These vegetables have many healthy properties, but their sulfur content is the standout nutrient you have probably never heard of. In fact, sulfur is what gives all those vegetables their pungent smell.

Sulfur is vital to your health for many reasons. It is the most abundant mineral element in our body after calcium and phosphorus. It is an important building block of some proteins – helping to form everything from muscle to connective tissue and even your skin. It is sulfur’s

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critical role in detoxication and halting cellular damage that is not given enough attention. Glutathione is the master detoxifier of the body, and your bodies manufacture it (if you provide the raw materials). One of those critical raw materials is sulfur. Glutathione is so powerful because of the sticky sulfur it contains. Free radicals (the “bad guys” that cause cellular damage) stick to the sulfur and glutathione disarms the intruder. Sulfur’s role in detoxication cannot be overstated. Consuming plenty of sulfur helps you keep glutathione levels high. It is an important part of your body’s defense against everything from colds to cancer. Glutathione is being studied as both a defense against and treatment for COVID-19. Some researchers theorize that the increased severity of COVID-19 in older individuals is in part because of lower glutathione levels. Poor diets and the aging process both slow down glutathione production and leave you at risk for chronic health issues like cardiovascular disease, chronic fatigue and neurological disorders. Sulfur supplementation has not yet shown clear results. What is clear is that eating high-sulfur foods throughout your day does have a wonderful synergistic

effect. Sulfur has the power to not only defend your body and brain, but to boost your energy and even improve your complexion. Those in-season brassicas are powerful and delicious medicine. Glucosinolates, the sulfur containing molecules found in brassicas have been shown in studies to prevent amyloid beta-induced oxidative damage that forms in neurodegenerative disorders like Alzheimer’s. Sulfur is an essential nutrient meaning your bodies cannot make it. You must ingest it. The cold weather brassicas I mentioned above are great sources but so are meat and poultry, seafood, alliums (onions, leeks, garlic, shallots, etc.), mushrooms, asparagus, eggs, beans, nuts and dairy. My suggestion is to eat 2-3 servings a day of sulfur-rich produce. Winter is a great time to get into that habit since they are in season and at their peak of flavor. I want to leave you with a few ideas to get more sulfur-rich brassicas onto your plate. • Use your food processor to quickly shred Brussels sprout. Then use them to make a coleslaw or a quick sauté (try them with some bacon and apple!). • Use raw cauliflower to make a WWW.ORTODAY.COM

OPERATING ROOM SOLUTIONS cauliflower-based tabbouleh (head to SmallWonderFood.com for my recipe). • Toss broccoli and/or cauliflower in olive oil and desired spices and roast on a sheet pan. Freeze in meal sized portions for a quick side dish. • Add frozen kale to anything and everything. It’s a great addition to soups, casseroles, hashes and skillet meals. Enjoy!

Surgical Table Pads, Casters, Mayo Stands and more!

REFERENCES Jaafaru, Mohammed Sani, et al. “Protective Effect of Glucosinolates Hydrolytic Products in Neurodegenerative Diseases (NDDs).” Nutrients, vol. 10, no. 5, 8 May 2018, www.ncbi.nlm.nih. gov/pmc/articles/PMC5986460/, 10.3390/nu10050580.

ALCO has your solution! Kirsten Serrano is a nutrition consultant, chef, farmer, food literacy educator and the best-selling author of “Eat to Your Advantage.” You can find out more about her work at SmallWonderFood.com.

800.323.4282 • WWW.ALCOSALES.COM

2021 VIRTUAL CODING & REIMBURSEMENT SEMINAR January 11, 19 & 25 This popular seminar—now a virtual event—provides essential training for ASC billers and coders.

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DECEMBER 2020 | OR TODAY |

OUT OF THE OR recipe

Grass-fed Beef Meatballs with Garlic and Herbs INGREDIENTS: Beef Meatballs: • Oil

Recipe

• 1 pound New Zealand grass-fed ground beef

the

• 1 cup fresh white breadcrumbs • 3 cloves garlic, crushed • 1 egg, lightly beaten • 3 tablespoons milk • 1 1/2 teaspoons Worcestershire sauce • 1 teaspoon dried mixed herbs, such as parsley, thyme and oregano • salt, to taste • pepper, to taste Tomato Sauce: • Oil • 1 onion, finely chopped • 2 cloves garlic, sliced • 1 can (14 ounces) chopped tomatoes, in juice • 1 1/2-2 cups vegetable stock • 1 tablespoon tomato paste • 1 teaspoon sugar • 1 bay leaf • salt, to taste • pepper, to taste To Serve: • 1/3 cup freshly grated Parmesan cheese • 1/2 cup roughly chopped parsley leaves

By Family Features

56 | OR TODAY |

DECEMBER 2020

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OUT OF THE OR recipe

A Flavorful Family Meal for Cold Nights By Family Features

arm, delectable dishes go hand-in-hand with cool evenings when

W the crisp air sends you to the kitchen for a filling meal. Look no further than easy recipes like meatballs that pack fulfilling flavor to feed your family when the temperatures dip.

These Grass-fed Beef Meatballs with Garlic and Herbs can be the perfect solution anytime youâ&#x20AC;&#x2122;re craving a warm, comforting meal. Theyâ&#x20AC;&#x2122;re made with New Zealand grass-fed ground beef, which provides an unrivaled taste. Grassfed year-round, the animals roam and graze freely over lush green hills and pastures, resulting in lean, flavorful meat that tastes just as nature intended. Paired with a tomato-based sauce, the meatballs are baked before being topped with Parmesan cheese and parsley then served hot for a dish that warms you from the inside-out. While preparing the meatballs, be sure to wet your hands prior to shaping them as it helps prevent the meat from sticking to your hands. Find more comforting fall recipes at beefandlambnz.com.

Grass-fed Beef Meatballs with Garlic and Herbs Prep time: 15 minutes Cook time: 25 minutes Servings: 4 1. To make beef meatballs: Preheat oven to 425 F. 2. Lightly oil deep baking dish or skillet. Mix beef, breadcrumbs, garlic, egg, milk, Worcestershire sauce, mixed herbs and salt and pepper, to taste, then shape into eight meatballs and place in prepared baking dish. 3. To make tomato sauce: In heavy saucepan over low heat, heat dash of oil and add onion and garlic. Cook until onion is soft, about 10 minutes. Add tomatoes, stock, tomato paste, sugar, bay leaf and salt and pepper, to taste. 4. Simmer 10 minutes to allow flavors to mingle and liquid to reduce. Remove from heat, cool about 5 minutes and remove bay leaf. In food processor, process until sauce is smooth. 5. Pour sauce over meatballs and bake 25 minutes, turning meatballs after 15 minutes. 6. Serve hot sprinkled with Parmesan cheese and chopped parsley.

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BUILD HEART-HEALTHY BEHAVIORS FOR PRESCHOOLERS AT HOME

pressing concern like a global pandemic can quickly overshadow other important health challenges facing families. One is the issue of childhood obesity, a problem the slower pace of life brought on by COVID-19 could exacerbate. Numerous cardiovascular and mental health risks are associated with childhood obesity, and many experts expect to see increases in both mental health challenges and obesity as a result of COVID-19. According to the Centers for Disease Control and Prevention, childhood obesity impacts 40% of children between the ages of 2-5, increasing their risk for Type 2 diabetes, asthma and depression. Data from a study published in the Early Childhood Education Journal from the American Heart Association shows children diagnosed as overweight between 7-13 years old may develop heart disease as early as age 25. However, preventative steps taken in early childhood can help reduce this risk. Keeping young children healthy while at home during the pandemic requires extra attention to their nutrition, physical activity and screen time. Programs like the American Heart Association’s Healthy Way to Grow, a national, science-based, early childhood technical assistance program, provide educational resources to help communities, educators and caregivers improve practices and policies for obesity prevention. These tips from the program can help early childhood professionals and caregivers promote best practices into the daily lives of children.

Nutrition Less than 1% of children have ideal diets, and under 10% have reasonably healthy diets, according to the American Heart Association. On any given day, 27% of 2- and 3-year-olds don’t eat a vegetable; among those who do, fried potatoes, which are high in fat and lower in nutrients, are most common. In fact, data shows kids eat less nutritious foods up to age 19. Children should consume a variety of foods daily, including vegetables, fruits, nuts, whole grains, low-fat or fat-free dairies, lean vegetable or animal protein and fish. At the same time, kids should minimize trans fats, processed meats, refined carbohydrates and sweetened beverages.

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Consistently timed meals and pairing new foods with choices they already enjoy are two ways to help form healthier habits. Be aware that healthy choices should apply throughout the day, not only for meals but also snacks and beverages. Eating together as a family provides an opportunity to model healthy eating and encourage children to try new foods. Also make water available and accessible to children throughout the day. For infants, feeding provides nutrition for their physical and mental growth. Healthy babies usually double their birth weight between 4-5 months of age. Infants and children with congenital heart disease and congestive heart failure or cyanosis (blueness) tend to gain weight slower. An 8-ounce-1-pound gain in a month may be an acceptable weight gain for a baby with a heart defect.

Physical Activity Only about 20% of kids perform enough activity to meet physical activity recommendations. Whether you’re working with children in a childcare setting or at home, look for ways to incorporate lesson plans that offer learning experiences about healthy eating and physical activity, and ensure the daily schedule includes ample active playtime. The Healthy Way to Grow program recommends all children, including infants, have at least two outdoor active playtimes daily, weather and air quality permitting. Toddlers should engage in 60-90 minutes while 120 minutes of daily active play is recommended for preschoolers. Half the time should be structured and led by a teacher or caregiver while the remaining playtime should be unstructured and up to the child. Learn more about protecting the health and wellness of children in your home and community at healthywaytogrow.org. – Family Features

DECEMBER 2020 | OR TODAY |

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INDEX

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ALPHABETICAL 3M……………………………………………………………………… BC

Cygnus Medical………………………………………………… 49

MedWrench……………………………………………………… 52

Action Products, Inc.……………………………………… 27

Encompass Group…………………………………………… 23

OR Today Webinar Series…………………………………21

AIV Inc.…………………………………………………………………15

GelPro…………………………………………………………………… 11

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

ALCO Sales & Service Co.……………………………… 55

Healthmark Industries Company, Inc.……………17

SIPS Consults………………………………………………………51

ASCA………………………………………………………………… 55

Innovative Medical Products…………………………IBC

TBJ Incorporated………………………………………………… 5

Augustine Temperature Management…………… 4

MD Technologies Inc.……………………………………… 25

TIDI………………………………………………………………… 32, 33

ANESTHESIA

INFECTION CONTROL

REPROCESSING STATIONS

Augustine Temperature Management…………… 4

ALCO Sales & Service Co.……………………………… 55

MD Technologies Inc.……………………………………… 25

ASSOCIATION

Cygnus Medical………………………………………………… 49

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

Encompass Group…………………………………………… 23

TBJ Incorporated………………………………………………… 5

Healthmark Industries Company, Inc.……………17

SAFETY

CATEGORICAL

ASCA………………………………………………………………… 55

CARTS/CABINETS

MD Technologies Inc.……………………………………… 25

GelPro…………………………………………………………………… 11

ALCO Sales & Service Co.……………………………… 55

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

Cygnus Medical………………………………………………… 49

SIPS Consults………………………………………………………51

Healthmark Industries Company, Inc.……………17

TBJ Incorporated………………………………………………… 5

TIDI………………………………………………………………… 32, 33

CS/SPD

INSTRUMENT STORAGE/TRANSPORT

MD Technologies Inc.……………………………………… 25

Cygnus Medical………………………………………………… 49

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

STERILIZATION

DISINFECTION

TIDI………………………………………………………………… 32, 33

3M……………………………………………………………………… BC

Cygnus Medical………………………………………………… 49

ONLINE RESOURCE

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

MedWrench……………………………………………………… 52

DISPOSABLES

OR Today Webinar Series…………………………………21

ALCO Sales & Service Co.……………………………… 55

OR TABLES/BOOMS/ACCESSORIES

ENDOSCOPY

Action Products, Inc.……………………………………… 27

Cygnus Medical………………………………………………… 49

Innovative Medical Products…………………………IBC

Healthmark Industries Company, Inc.……………17

OTHER

TIDI………………………………………………………………… 32, 33

MD Technologies Inc.……………………………………… 25

AIV Inc.…………………………………………………………………15

SURGICAL INSTRUMENT/ACCESSORIES

PATIENT MONITORING

Cygnus Medical………………………………………………… 49

AIV Inc.…………………………………………………………………15

Healthmark Industries Company, Inc.……………17

PATIENT WARMING

TELEMETRY

Encompass Group…………………………………………… 23

AIV Inc.…………………………………………………………………15

POSITIONING PRODUCTS

TEMPERATURE MANAGEMENT

Action Products, Inc.……………………………………… 27

Augustine Temperature Management…………… 4

Cygnus Medical………………………………………………… 49

Encompass Group…………………………………………… 23

MD Technologies Inc.……………………………………… 25

Innovative Medical Products…………………………IBC

GENERAL

WASTE MANAGEMENT

PRESSURE ULCER MANAGEMENT

MD Technologies Inc.……………………………………… 25

AIV Inc.…………………………………………………………………15

Action Products, Inc.……………………………………… 27

TBJ Incorporated………………………………………………… 5

HOSPITAL BEDS/PARTS

REPAIR SERVICES

ALCO Sales & Service Co.……………………………… 55

Cygnus Medical………………………………………………… 49

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

FALL PREVENTION ALCO Sales & Service Co.……………………………… 55 Encompass Group…………………………………………… 23

FLOOR MATS GelPro…………………………………………………………………… 11

FLUID MANAGEMENT

62 | OR TODAY |

DECEMBER 2020

Healthmark Industries Company, Inc.……………17 TIDI………………………………………………………………… 32, 33

SINKS Ruhof Corporation……………………………………………2, 3 TBJ Incorporated………………………………………………… 5

Cygnus Medical………………………………………………… 49 Healthmark Industries Company, Inc.……………17 MD Technologies Inc.……………………………………… 25 TBJ Incorporated………………………………………………… 5

SURGICAL MD Technologies Inc.……………………………………… 25 SIPS Consults………………………………………………………51

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LINT FIBERS DON’T BELONG IN THE OR Cloth towel bundles are the #1 contributor to lint and moisture contamination in the O.R.* Why bundle when you can bump for safety & control of contamination? Ready-to-use Guaranteed sterile, dry & latex free Reduces pressure sores Saves on SPD labor & material costs

SteriBump

The IMP® SteriBump® is a latex-free, contoured polyurethane foam block with a closed-cell geometry that significantly reduces foreign particulates during surgery. Protected by guaranteed sterile packaging, and ready to use for multiple applications, SteriBump ensures product sterility while providing the patient and the surgical team a soft, yet firm physical platform to securely elevate a patient’s limb in the sterile field when required.

FREE sample: www.impmedical.com or call 800.467.4944 The operative word in surgical patient positioning

*W. Truscott, Ph.D. Impact of Microscopic Foreign Debris on Post Surgical Complications, Surgical Tech, Int. XII 2004 pg 35. **L. Page, Materials Magn Mar. 05 pg. 243-W.Truscott, Ph.D. Impact of Microscopic Foreign Debris on Post Surgical Complications, Surgical Tech, Int. XII 2004, 41. Dust shown is not actual and has been added for dramatic purposes only. imp® products are protected by patent & patent pending rights. Visit impmedical.com/patents. All Rights Reserved. ©2020 IMP

Protect your patients. Every time. Before the COVID-19 pandemic, pre-op nasal decolonization was reserved for high risk patients. Today it’s recommended for every patient.1,2 3M™ Skin and Nasal Antiseptic helps reduce the risk of surgical site infections (SSIs) when part of a comprehensive preoperative protocol.3,4,5 A one-time application of 3M™ Skin and Nasal Antiseptic can help reduce nasal bacteria, including S. aureus by 99.5 percent, in just one hour and maintain that reduction for at least 12 hours.6

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Loftus RW, Dexter F, Goodheart MJ, et al. The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial. JAMA Netw Open. 2020;3(3):e201934. doi:10.1001/jamanetworkopen.2020.1934. Dexter F, Parra MC, Brown JR, Loftus RW. Perioperative COVID-19 Defense: An Evidence-Based Approach for Optimization of Infection Control and Operating Room Management. Anesth Analg. 2020Mar 26. doi: 10.1213/ANE.0000000000004829. [Epub ahead of print] Phillips M, Rosenburg A, Shopsin B, et al. Preventing surgical site infections; A randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution. Infect Control Hosp Epidomiol. 2014;35(7):826-832. Urias DS, Varghese M, Simunich T, Morrissey S, Dumire R. Preoperative decolonization to reduce infections in urgent lower extremity repairs. Eur J Trauma Emerg Surg. 2018;44(5):787-793. doi:10.1007/s00068-017-0896-1. Torres EG, Lindmair-Snell JM, Langan JW, Burnikel BG. Is preoperative nasal povidone-iodine as efficient and cost-effective as standard methicillin-resistant Staphylococcus aureus screening protocol in total joint arthroplasty? J Arthroplasty. 2016;31(1):215-218. 3M Data on File: 05-011100. 3M is a trademark of 3M. © 3M 2020. All rights reserved.