OR Today Magazine January 2021 by MD Publishing

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LIFE IN AND OUT OF THE OR

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OR TODAY | January 2021

contents features

PREVENTING PATIENT FALLS Patient falls are dangerous for patients and can lead to extended hospital stays. The financial impact of patient falls is also significant – the cost of these falls averages $30,000 per hospital stay or $50 billion total per year. Experts share tips on how to prevent patient falls.

WOUND CARE MARKET TO HIT $24 BILLION BY 2027 The global wound care market size is projected to showcase significant progress and exceed $24 billion by 2027, according to at least one report.

This activity explores the art and science of caring in the nursing profession and its role in the health care environment of cost containment.

Learning about behavioral styles is extremely helpful for creating better teamwork and increased productivity. As a bonus, behavioral styles are easy to learn with only four main styles.

CARING: THE ESSENCE OF NURSING

IDENTIFYING BEHAVIORAL STYLES

OR Today (Vol. 21, Issue #1) January 2021 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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8 News & Notes 16 ASCA: As ASCs Prepare for 2021, ASCA Stands Ready to Help 18 Surgery Starts Here: Surgical Site Infection Prevention is a Team Effort 20 IAHCSMM: Prioritizing Surgical Instrumentation in Sterile Processing Departments 22 CCI: Becoming a Perioperative Nurse The Historical Context 23 AAMI: Sterilization Leaders Pool Knowledge in Unprecedented Collaboration 24 Webinars: Presenter Shares Patient Positioning Insights

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WEBINARS Jennifer Godwin

EDITORIAL BOARD Beyond Clean

26 M arket Analysis: Wound Management 27 Product Focus: Wound Management 30 CE Article: Caring: The Essence of Nursing

Sharon A. McNamara, Perioperative Consultant, OR Dx + Rx Solutions for Surgical Safety

OUT OF THE OR

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IN THE OR

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INDUSTRY INSIGHTS

news & notes

AAAHC Earns ISQua Accreditation The Accreditation Association for Ambulatory Health Care (AAAHC) was recently awarded a 4-year accreditation of its health care standards from the International Society for Quality in Health Care’s (ISQua) External Evaluation Association (IEEA) International Accreditation Programme (IAP). Launched in 1999, the IEEA IAP is a rigorous assessment process that reviews existing accreditation standards and processes to confirm they meet international industry requirements for patient safety and ongoing quality improvement. Operating in more than 60 countries, the IEEA IAP provides third-party external evaluation services to health and social care external evaluation organizations and standards developing bodies around the globe. The IEEA IAP accreditation encourages growth and development through an ongoing review process that includes

a comprehensive self-assessment against ISQua principles, intense peer review evaluation of standards and supporting evidence by ISQua surveyors and an in-depth validation review by the IEEA Accreditation Council. Also, the AAAHC has published version 41 of the Accreditation Handbook for Health Plans and the Accreditation Handbook for FEHB Health Plans. The revised editions provide the most current, trusted information and guidance for organizations seeking AAAHC accreditation that meets stringent operational and program requirements in such areas as quality and risk management, member rights and utilization management, patient safety and provider credentialing. • For more information, visit www.aaahc.org.

3M Expands Surgical Portfolio 3M has announced the availability of its Prevena Restor Axio-Form Incision Management System, designed to manage post-operative incisions, as well as the surrounding soft tissue envelope, following the orthopedic surgical repair of lower extremity fractures. Prevena Restor Axio-Form helps stabilize the incision and surrounding soft tissue, reduce edema and help enhance post-operative recovery. This is the third offering in the Prevena Restor Therapy portfolio, launched in 2019, to optimize post-surgical care and expand the company’s specialty surgical offerings. “Patients recovering from lower extremity fractures often experience complications which can potentially compromise the healing process, leading to delayed rehabilitation and poor functional outcomes,” said Dr. Brett D. Crist, MD, FAAOS, FACS, FAOA, director of orthopaedic surgery, University of Missouri School of Medicine, who participated in the pre-market pilot. “The Prevena Restor Axio-Form System provides a unique solution for post-surgical incision and soft tissue envelope management for the lower extremity – which can be one of the most complex and challenging anatomical areas. The expanded coverage and precision design lend themselves to better conformity

OR TODAY | January 2021

on the surgical site, providing us confidence for our patients’ recovery.” The Prevena Restor Axio-Form System encompasses the same proven technology as the Prevena Incision Management System, with added benefits including: • Extended therapy time: up to 14 days (dressing change required after seven days); • Expanded coverage area: dressing seamlessly conforms to the patient; • Precision design: larger dressing delivers therapy to incision and surrounding soft tissue envelope; • Mechanically stabilize the incision and surrounding soft tissue; • Easy to apply, form-fitting Peel & Place dressing. Also, 3M has announced that its TB Quat Disinfectant Ready-to-Use Cleaner has been approved by the U.S. Environmental Protection Agency (EPA) for kill claims against SARS-CoV-2, the virus that causes COVID-19. Third-party laboratory testing of 3M’s TB Quat Disinfectant Ready-toUse Cleaner confirmed the disinfectant’s efficacy against the virus with a 60-second contact time on hard, nonporous surfaces. •

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INDUSTRY INSIGHTS

news & notes

CHLA Surgeon Establishes Guidelines for Pediatric Opioid Prescribing According to the National Institutes of Health, opioid misuse and addiction in the United States is a national crisis, with an economic burden upwards of $78 billion. Opioids are useful for pain management following surgery and other major procedures, but until now there have been no recommendations guiding safe use of opioids in children. Pediatric Surgeon Lorraine Kelley-Quon, MD, MSHS, led a diverse team of health care providers and advocates to establish the first such guidance. Published in JAMA Surgery, KelleyQuon and her colleagues outline 20 guidelines for safer pain management in children and adolescents. “Many people are aware that there’s an opioid epidemic,” says Kelley-Quon, “but when I talk about my work, people are surprised to hear that it impacts children.” One of the primary concerns is the use of opioids among teens and adolescents. Kelley-Quon cites a CDC report revealing that approximately 9 percent of teens aged 15-19 report receiving an opioid prescription in 2018. This age group is of concern because prescription medications can be used recreationally and shared with friends. In addition, research shows that death due to opioid overdose is on the rise for all age groups. “Opioids can be very effective in pain management following pediatric procedures,” she says, “but we need to work with the medical community to ensure they are used safely and judiciously.” As a member of the American Pediatric Surgical Association’s Outcomes and Evidence-Based Practice Committee, Kelley-Quon led an effort to develop evidence-based guidelines for best practice in opioid prescribing. Her team did an extensive review of scientific and medical publications, but the effort went far beyond a literature search. Kelley-Quon created

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a multidisciplinary group that included specialists in pediatric surgery, pediatric anesthesia, and addiction science, and included other key stakeholders representing nursing, physician assistants, surgery trainees, and family advocates. After pooling data from published studies, the entire group met and constructed the guidelines together. “Opioid prescribing doesn’t just impact what a pediatric surgeon does,” says Kelley-Quon. “Nurses and other medical care providers are involved in pain management discussions with patients and their families, so we wanted their input as well.” The team came up with three basic tenets, into which all the guidelines fall. First is simply a recognition that misuse of prescription opioids is a problem to be taken seriously when caring for children and adolescents. Second is to acknowledge there are many non-opioid medications that have excellent data supporting their use for children who require surgery. The team reviewed and presented those options. Finally, health care providers must educate patients and families before and after surgery about what an opioid is, what the risks are, and how they should be safely stored and disposed of. “With these guidelines, we didn’t want to suggest that opioids should never be used,” says Kelley-Quon. “Instead, we wanted to impart the idea that they need to be used in a thoughtful way.” Just as health care providers and patients have come together around the idea of antibiotic stewardship—using an antibiotic only when medically necessary to prevent development of antibiotic-resistant bacteria—she says we should practice opioid stewardship. The publication, endorsed by the American Pediatric Surgical Association, sets the stage to begin shaping policies around prescribing opioids in pediatric medicine, but Kelley-Quon says we are not there yet. •

January 2021 | OR TODAY

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KARL STORZ Imaging Celebrates 30th Anniversary

Healthmark Offers New Cable Continuity Tester Healthmark Industries has introduced the Cable Continuity Tester to its ProSys Instrument Care product line. Designed to test the quality of monopolar and bipolar cords, the Cable Continuity Tester is user-friendly and portable. For the desired test, simply position the “ON” switch to bipolar or monopolar. If the green light remains illuminated, then the cable passed testing. If the light flickers or doesn’t illuminate, this indicates the cable failed testing. Each Cable Continuity Tester comes with a 9V battery and a carrying case. •

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KARL STORZ Imaging (KSI) of Goleta, California, celebrated its 30th anniversary on November 12, 2020. Since 1990, KSI has been a pillar of California’s Central Coast technology industry and is one of the area’s largest employers, with almost 400 team members. KSI is a subsidiary of KARL STORZ SE & Co. KG, a family-owned company based in Germany that employs more than 8,000 people in 44 countries. KARL STORZ is a world leader in endoscopes used for medical diagnostics and minimally invasive surgery, which can achieve shorter hospital stays and recovery times, with reduced pain and improved outcomes. As one of the largest privately held medical device companies in the world, KARL STORZ has achieved global preeminence in production and sales of endoscopes and medical imaging devices. In 1990, KARL STORZ purchased the Goleta startup, Medical Concepts, Inc., creating KARL STORZ Imaging. For 30 years, this local high-tech company has thrived. KSI put down more permanent roots in 2014 by purchasing its current building at 1 South Los Carneros Rd. with an eye on expansion. This 100,000-plus square foot facility houses the internationally renowned product development group, integrated with high-tech manufacturing and service. KSI has made significant advances in medicine while contributing to the economic growth of the Central Coast of California. This success was recognized in 2015 with the dedication of its street as Karl Storz Drive. The KARL STORZ Imaging 30th anniversary celebration will be held virtually with global participants. They look forward to recognizing this historic company milestone with employees, the community, and special guests. •

January 2021 | OR TODAY

INDUSTRY INSIGHTS

news & notes

Mölnlycke’s New Skin-Friendly Surgical Gloves Mölnlycke celebrated World Handwashing Day with the launch of the innovative Biogel PI UltraTouch S surgical glove, which addresses the problem of allergic contact dermatitis among surgical teams. Frequent handwashing and exposure to chemicals all contribute to occupational contact dermatitis. Exposure to chemical additives used in the manufacturing of gloves can cause irritant or allergic contact dermatitis.

Almost one-third of surgeons and nurses indicate they suffered a skin reaction in the operating room, according to a recent survey. The latest addition to the Biogel product line, Biogel PI UltraTouch S surgical gloves have been designed with a new skin-friendly formula that is clinically proven to minimize the risk of allergic contact dermatitis in the operating room. It is the first surgical glove to be cleared by the FDA to re-

duce the potential for sensitizing users to chemical additives. Offering the same precision, tactile sensitivity and perforation detection that has made Biogel the trusted favorite of healthcare professionals worldwide, Biogel PI UltraTouch S are made without the chemical accelerators known to cause allergic contact dermatitis. Symptoms of allergic contact dermatitis include redness, cracked skin, sores, open lesions and scabbing. •

oneSOURCE Announces New Safety Data Sheets Database In the third quarter of 2020, oneSOURCE announced its newest database for Safety Data Sheets (SDSs) will support safety officers, sterile processing departments, professionals working in the operating room and more. The new library offers customers unrivaled access to thousands of SDSs, from the latest sheets to an archive of over 30 years’ worth of critical materials. With a focus on maintaining or exceeding OSHA compliance standards, the database arms safety managers and hospital and surgical staff with 24/7 access to a fully searchable platform of unlimited documents, ensuring the highest level of patient care. “Here at oneSOURCE, we have a unique opportunity to serve our healthcare customers well by sourcing these important safety data sheets in an easy-to-use and approachable format,” said Jack Speer president of oneSOURCE. “Our intention for this new database is to pave the communication and information foundation for our customers in order to allow them to act efficiently and effectively in the case of a hazardous incident.” Safety Data Sheets (SDSs) are used as an industry-wide source to instruct workers on how to mitigate chemical exposure to patients and staff including the safety precautions

OR TODAY | January 2021

for handling, storing, and transporting. This new SDS database provides users with unlimited access to thousands of documents at their fingertips in a matter of seconds. “With the new SDS database we are able to provide healthcare professionals with incredibly important materials that traditionally have been difficult to acquire due to the archaic nature of how they were organized, accessed and stored,” said Heather Thomas, CMO and executive VP of sales and marketing of oneSOURCE. “This new offering is the answer to decades of frustration from practitioners. oneSOURCE is committed to continuing to develop platforms that allow our partner facilities to thrive and ensure the wellbeing of patients and staff.” The SDS database is a necessary addition to the company’s extensive product line and enables unlimited usage to safety procedures. Leading healthcare organizations, including Trinity Health, Sutter Health, VHA, and HCA, continue to partner with oneSOURCE as it gains unprecedented traction and demand both domestically and internationally. • For more information, visit onesourcedocs.com.

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Encompass Introduces Nova Effective Patient Warming Encompass Group LLC has announced its Nova Next-Generation Patient Warming. Nova warms patients without air movement, reducing infection risks associated with forced air. With no moving parts, the Nova system is silent, creating no additional noise in the OR. The Nova blanket is easy to apply and to keep on your patient. The controller unit is intuitive and simple to operate. Nova banks a patient’s heat before surgery and maintains normothermia throughout the surgical process. The Nova blanket doesn’t emit excess heat, so patients stay warm while clinicians remain cool during surgery. Nova was designed with both the caregiver and patient in mind. Upper and lower body products are available. •

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January 2021 | OR TODAY

INDUSTRY INSIGHTS

news & notes

ReadySet Surgical Launches RS Analyze ReadySet Surgical recently announced the launch of RS Analyze. RS Analyze provides hospital supply chain, operating room and sterile processing department leaders with unmatched real-time data that will allow them to proactively take corrective actions. These actions lead to improved vendor performance, from on-time delivery to price accuracy and contract compliance. “Recent data suggest a significant backlog of orthopedic and neurosurgical cases, placing even more pressure on hospital leaders looking for solutions to better manage vendors, personnel and inventory across the supply chain. Data analytics and reporting from RS Analyze provide supply chain, OR and sterile processing leaders information they need to proactively take corrective action, leading to lower total costs,” says ReadySet Surgical Founder and CEO Keerthi Kanubaddi. “RS Analyze was developed jointly

with ReadySet Surgical customers and includes those metrics on which hospital leaders expressed a desire to trend continuously and use as part of their vendor management and business review process. RS Analyze consolidates vendor and surgeon data to provide actionable insights on contract compliance, product standardization and utilization. Our customers expressed a desire to receive these data prior to the scheduled procedure date enabling actions that will reduce overall costs,” says Anthony Shimkin, ReadySet Surgical’s chief marketing officer. With the addition of RS Analyze, the ReadySet Surgical portfolio removes the threat of lost instrument charges, significantly reduces expedited freight charges, eliminates pricing discrepancies and improves contract compliance virtually from the first day of implementation. As a result of the platform’s ability to compile actionable data, ReadySet can also work

with major medical device manufacturers to capture synergies throughout the global supply chain. With the addition of RS Analyze, ReadySet Surgical is arming leaders from hospitals and device manufacturers with tools they need to reduce costs and create greater efficiencies. ReadySet Surgical’s comprehensive end-to-end platform also includes RS Track, RS Coordinate, and RS Capture, which debuted in September 2020. In combination with RS Analyze, these solutions reduce hard-dollar process costs and significantly reduce staff workload related to inventory management, guaranteeing savings opportunities for customers. ReadySet Surgical is committed to introducing technology solutions that help health care systems and manufacturers work together to eliminate unnecessary process and product costs, while maximizing the focus on patient care activities. •

Sony Expands Lineup of 4K Medical Monitors Sony’s latest 4K LCD display, the LMD-X3200MD, is a multifunctional 32-inch medical monitor ideal for use in hospital operating rooms, surgical centers and clinics. It combines high picture quality, installation flexibility and ease of use, with advanced features including wide color gamut, HDR support, and a variety of display modes. This ergonomic new offering rounds out Sony’s lineup of 4K LCD displays, adding a mid-range option at a competitive price, that complements the flagship LMD-X310MD 31-inch monitor and the compact LMDX2700MD 27-inch monitor, while similarly providing enhanced visualization and up scaling of HD/SD images. In addition to a wide color gamut and HDR support for accurate colors and detailed shadow areas and built-in image enhancement, the LMD-X3200MD offers immersive

OR TODAY | January 2021

imagery in a 16:9 aspect ratio with 4K UHD resolution (3840x2160) for four times the clarity of full-HD. With a contrast ratio of 1,000:1 and a luminance of 500cd/m2, the monitor provides increased optical performance in bright and dark environments. It also features new Sony-unique Advanced Image Multiple Enhancer (A.I.M.E.) technology for optimally adjusting the color, contrast and visibility of the dark areas, as well as shadow, structure and color enhancement, in addition to noise reduction, for more comfortable and realistic viewing with better image reproduction. •

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Stryker Offers Wireless Hospital Bed Stryker has announced the global launch of its completely wireless hospital bed, ProCuity. This intelligent bed was designed to help reduce in-hospital patient falls at all acuity levels, improve nurse workflow efficiencies and safety, as well as help lower hospital costs. It is the only bed on the market today that can connect seamlessly to nurse call systems without the use of cables or wires.  “Patient safety is at the foundation of everything we do at Stryker. With rising acuity rates leading to increased bed demand, coupled with the continuing challenge of in-hospital falls, we needed to find a solution to further enhance our response to some of today’s most pressing health care challenges,” said Jessica Mathieson, vice president/general manager of acute care, Stryker. “Leveraging our long history in innovation, ProCuity is the culmination of years of extensive research and feedback from nurses and other health care professionals to create what is truly a ‘brilliance in a bed’ solution. It was designed to improve patient outcomes and assist caregivers for years to come.”  Research shows that between 700,000 and 1 million patients experience a fall while being treated in the hospital annually, with 79 percent of falls occurring on or near a bed while unassisted. Stryker’s own research found that 97 percent of hospital nurses reported having encountered a situation where a patient has had difficulty getting out of a hospital bed, with 75 percent reporting they have encountered a situation where a patient has hurt him or herself while getting out of a hospital bed. Anywhere from 30 to 51 percent of in-hospital falls result in injuries.  Set at an industry-low height of 11.5 inches, ProCuity is ergonomically designed with the latest technologies to promote safe patient handling and help reduce fall-related injuries, including intuitive patient positioning and bed alarms as well as ergonomic side rails. Helping to address nurse call cable connectivity issues prevalent in hospitals today, ProCuity can be equipped with fully wireless features. Additionally, the bed’s easy-to-use touchscreens and other key components make the job of caregivers easier and more efficient, while providing for a more enhanced patient experience. •

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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January 2021 | OR TODAY

INDUSTRY INSIGHTS CCI ASCA

As ASCs Prepare for 2021, ASCA Stands Ready to Help By Bill Prentice eading into 2021, COVID-19 continues to make headlines and the results of the 2020 elections are just beginning to become reality. People around the world are tossing out the crystal balls they used to predict the New Year in the past. They are hoping that with 2020 behind us, the coronavirus and other disruptions will disappear as well.

At the same time, following a familiar path, policy makers in Washington, D.C., and across the country continue to search for ways to make affordable, accessible, high-quality health care available everywhere. ASCA has a full agenda in place to support these efforts inside ASCs in the coming year. As we did in 2020, ASCA will remain committed to being a timely and reliable resource on COVID-19. Whether the news of the day is about clinical developments, the equipment and resources needed to respond to patients affected by the virus, financial relief for health care providers or some other aspect of the national response to the vairus, ASCA will do everything it can to provide the kind of complete and accurate information needed to support appropriate and meaningful 16

OR TODAY | January 2021

action within individual ASCs and the entire ASC community. ASCA will also continue to advocate for wise policy decisions on behalf of ASCs and their patients for the duration of the COVID-19 pandemic. As we learned in 2020, without a strong, fully informed voice on behalf of ASCs and patients in need of the services ASCs provide, decisions and response planning at both the national and state levels could easily go astray. In 2020, ASCA was instrumental in heading off some well-intended but uninformed proposals that would have undermined the value of the care ASCs have been providing during this pandemic, and ASCA is committed to continuing to serve in that role in 2021. At the same time, ASCA will continue to advocate for several changes in Medicare policy that will support patient access to ASCs. As I have indicated in this column previously, those that will be at the top of our list include: • continued use of the same factor – currently the hospital market basket – to update both ASC and HOPD payments for inflation each year; • enactment of appropriate payment rates for all device-intensive procedures; • adoption of copay caps in ASCs that match those available in hospital outpatient departments

(HOPD); and elimination of a budget neutrality adjustment Medicare uses now to determine ASC payments that disincentivizes volume from migrating to ASCs and contributes to a growing disparity in ASC and HOPD rates. If adopted, each of these proposals would improve patient access to the many benefits ASCs provide and support the accessible, affordable, high-quality outpatient surgical care that patients and policy makers are seeking. Private insurers and their beneficiaries, whose plans are often built on Medicare’s model, also stand to benefit as these policies are adopted. But ASCA’s plans related to COVID-19 and ASC information and advocacy are only one part of ASCA’s 2021 agenda. To help the health care professionals who work in ASCs be at their best while coping with the impact COVID-19, ASCA is releasing several new resources and retooling some popular educational programs. Last November, putting a priority on the health and safety of all involved, ASCA announced that ASCA 2021 – our annual conference originally scheduled as an in-person event in Washington, D.C. – will be an entirely virtual event. Updated information on the conference is being added to ASCA’s website as •

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INDUSTRY INSIGHTS ASCA

available. You can learn more about that conference and all the resources described below on ASCA’s website, www.ascassociation.org. With all the online programming that is available now, we have also redesigned our webinar series to help participants make certain they are investing their limited time wisely in the areas that interest them most. This year, for purchasers of our all-access pass, we are offering specialized tracks for materials managers, clinical directors, infection preventionists and administrators. Of course, participants do not have to hold those titles or fill those roles to attend any of the sessions and are not limited to participating in just one track. The tracks are a tool that help subscribers identify and access the programs that best address their needs. ASCA has also introduced several additions to its Clinical & Operational Benchmarking Survey. The survey now includes optional specialty reporting tracks in total joint, complex spine and, new in 2021, ophthalmology procedures. For ASCs interested in meeting the Accreditation Association for Ambulatory Health Care’s Advanced Orthopaedic Certification requirements, the survey also qualifies as a nationally recognized specialty-specific data repository. This year’s survey also comes with a new “Benchmarking Basics for ASCs” how-to guide that walks users through every step of the process and provides templates, real-life case studies and more that can help ASCs manage a successful quality assessment and performance improvement (QAPI) project. The new guide is available free to benchmarking survey subscribers only and cannot be purchased separately. WWW.ORTODAY.COM

“One part of ASCA’s 2021 agenda [is] to help the health care professionals who work in ASCs be at their best while coping with the impact of COVID-19.” This new guide will be the focus of another event ASCA is offering for the first time this year: a virtual book club discussion. All subscribers to ASCA’s Clinical & Operational Benchmarking Survey are invited to register free to join interactive conversations with the e-book’s authors. Participants are encouraged to bring questions, share their own experiences and consult with their colleagues and the authors about how the process works and ways to use benchmarking effectively to enact meaningful and lasting improvements in their ASC. To help ASCs make informed staffing and employee compensation decisions, ASCA is also conducting our popular Salary and Benefits Survey again this year. Every ASC can participate in this survey for free, and those that meet the reporting requirements receive access to free personalized reports that allow for data comparisons with other facilities. Also this year, ASCA will be offering a new ASC infection prevention (IP) course that will provide valuable content for ASC infection preventionists and a new “Management Essentials for ASC Administrators” course. We expect the IP course to be helpful to those planning to take the Certified Ambulatory Infection Preventionist (CAIP) exam and the management course to be useful to new administrators as well as

experienced administrators looking to refresh their knowledge and skills. That course should also be helpful to anyone preparing for the Certified Administrator Surgery Center (CASC) exam. For our members, ASCA is also on track to continue offering ASC Focus magazine, our members-only online community ASCA Connect and the members-only episodes of the Advancing Surgical Care Podcast series we introduced in 2020. We will also provide more of the publicly available episodes of that podcast when the topic being discussed has broad appeal. Health care providers across the board can expect 2021 to bring its own unique challenges. At ASCA, we are confident that ASCs will remain a popular choice for patients, physicians and insurers in the new year and beyond. I encourage everyone who wants to know more about ASCs to visit ASCA’s Advancing Surgical Care website, www.advancingsurgicalcare. It provides many useful tools, including an interactive map that allows users to find ASCs throughout the country. I also encourage any ASC that is not already a member of ASCA to join now. You can get the information you need on ASCA’s website at www.ascassociation.org/membership or by contacting Mykal Cox at mcox@ascassociation.org.

January 2021 | OR TODAY

INDUSTRY INDUSTRY INSIGHTS INSIGHTS Surgery Starts news Here & notes

Surgical Site Infection Prevention is a Team Effort By Brandon Huffman, BS, CRCST, CIS magine recovering at home after receiving a lifesaving surgical procedure last week. That whole incident was scary, but you’re glad it’s in the rearview mirror. You’ve been in pain from the procedure itself, but you generally have started to feel better the last couple days. Then, you wake up this morning feeling awful. You feel tired and miserable and you start spiking a fever. “What in the world is happening?” you ask yourself.

Your spouse calls the doctor to explain your current status and is told to go to the emergency room right away. As if your trauma from last week wasn’t enough trouble, now you’re once again scared not knowing what is brewing within your body to make you feel so horrible. Here you are again in the emergency room where it all started last week, and here comes that lab technician with more needles to poke you with. After some uncomfortable belly imaging and an eternity of waiting on results, your doctor breaks the news, you have a surgical site infection. She is going to start you on some powerful intravenous antibiotics and hopefully avoid having to surgically go back in to wash out your surgical site. “Go back in? How could this possibly have happened?” you ask yourself in terror. I wish I could say this was a rarity, but surgical site infections are a significant

problem in the United States. As an infection preventionist, I spend a lot of time reviewing infections to get a better understanding of what processes broke down and investigating what may have contributed to the infection in the first place. There are many things that can go wrong to contribute to an infection, but today I want to talk with you about infections resulting from sterile processing complications. When it comes to surgical instrumentation, sterile processing plays a critical role in the prevention of surgical site infections. The first area of concern is always cleaning. If all bioburden is not removed from an instrument it can provide a protective barrier to organisms underneath that may allow them to survive sterilization. And cleaning always starts at point of use. The myth I constantly run into is that sterile processing is responsible for cleaning, not the operating room. This may appear true in a broader sense, but the Association for the Advancement of Medical Instrumentation (AAMI), the Association of Operating Rooms Nurses (AORN), and the Association of Surgical technology (AST) all agree that cleaning is a shared responsibility. The sooner that bioburden is physically removed from dirty instruments, the greater the success for proper reprocessing of that instrument. Whomever uses that instrument at point of use is responsible to start the cleaning process, end of story. The next area of concern is instrument inspection. Bioburden can be extremely difficult to see with the naked

eye especially when you take into account department lighting, age of the inspector and location of the bioburden on the instrument. Sterile technicians need proper tools to illuminate and magnify the instruments they are assigned to inspect. Not to mention appropriate time to perform the inspection. Our next area of concern is sterilization. When performed correctly, sterilization can kill 100% of organisms that may be living on the instruments. “Performed correctly” is a bit of an understatement when it comes to the magnitude of nuances that can affect proper sterilization. The manufacturer’s instructions for use must be followed for proper packaging of the instrument, and also following the correct sterilization type and parameters. Sterilizers must also be loaded correctly in the right configuration to allow proper penetration of sterilant. This all is hopefully taking into account that you routinely test the efficacy of your sterilizers’ killing capabilities via biologicals in process challenge devices. And our last stop for concerns is the storage and final inspection of instruments when presented to the sterile field. Sterile storage must maintain proper temperature and humidity and be free from excess traffic stirring up dust and microorganisms. Upon opening instruments in the operating room, tamper evident devices must be checked including locks on sterile containers or tape on wrapped trays to ensure sterility was maintained between sterilization and surgery. Once the instruments are received

by the surgical technician or nurse on the sterile field, this is the last chance to verify cleanliness before use. Many times in my career, I have come across instruments that were opened to the sterile field that were found to be dirty. These are always great catches by our surgical teams, but absolutely concerning to me as a health care professional. I often wonder how dirty instruments got through so many checkpoints. And, even more worrisome, is how so many make it through this last checkpoint that we don’t even know about? Cleaning, disinfecting and sterilizing is an extremely tedious and complicated process in today’s surgical instrumentation world. Instruments are becoming more complex, harder to clean, and hos-

pitals continually get tighter with staffing levels and their ability to maintain skilled sterile technicians who are fully competent. With so many things that can complicate surgery and lead to surgical site infections, you don’t want your sterile processing department processes to be one of them.

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

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January 2021 | OR TODAY

INDUSTRY INSIGHTS

IAHCSMM

Prioritizing Surgical Instrumentation in Sterile Processing Departments By Angela Lewellyn, LPN, CRCST, CHL, CSPDT nstrumentation prioritization is a critical job for sterile processing (SP) professionals and helps keep surgeries on track and ensure that complete trays and other necessary items are available when needed for the operating room (OR). Among the most valuable methods for prioritizing instrumentation lies with the surgical schedule. Scheduled cases and add-on procedures should determine how SP teams prioritize instrumentation needed to build case carts for the following day’s business demands. Typically, the surgical schedule is posted the day prior to when the instruments are needed. All SP professionals, including technicians, leads, supervisors and liaisons, should know how to read the schedule.

SP professionals can prioritize instrumentation requests by categorizing them one of three ways: want, need or waste. Many instrumentation demands are considered urgent or are requested with a sense of urgency. Those in SP can determine priorities in one of these categories and control some of their daily duties by instituting processes that control these ongoing issues.

Building Trust to Capture Truly ‘Urgent’ Requests Often, an urgently needed (wanted) instrument requested from an OR team member arises due to an ur20

OR TODAY | January 2021

gent need for the patient as the team prepares for a procedure. Sometimes, the OR’s requests for extra instrumentation comes from a lack of trust between the OR and SPD. The OR team may request items to ensure they have instruments that a surgeon or provider “might” want or need. It’s important to note that OR teams may lack a strong degree of trust if the SPD provided incorrect instrumentation in the past, or if the instrumentation wasn’t received in the timeframe needed to ensure a successful procedure. Other urgent requests may stem from a surgeon requesting an unordinary instrument; therefore, the OR team may place that item on a surgeon’s preference list for future cases, even though the surgeon may never request the item again. Such circumstances can create tremendous pressure (and greater workload) for the SP team. Developing an OR/SP committee can help. Usually, I initially recommend getting together twice a month to discuss both departments’ needs. This interdisciplinary committee will ideally be comprised of an SP technician, surgery liaison, OR service coordinator and surgical technologist. I recommend these professionals for a collective and comprehensive approach to addressing mishaps and proactively discussing needs. In doing so, we can gain trust and appreciation for each team. Requests that fall under the “Need” category are usually standard instruments needed to perform surgical procedures (these are typically provided

on a surgeon’s preference card). An SP team can determine the needed items from the preference card for each scheduled case, usually the day before the procedure. To prioritize these needed items, the SP shift coordinator should over-communicate the needs. They can post needs on a communication board, huddle about these needs at the beginning of the shift and communicate those needs again in huddles at shift changes. Instruments/trays that were not completed and still in need can be communicated at this time. Once the needs are determined, the SP lead/supervisor for the shift can delegate or assign the need to technicians in the decontamination and assembly areas. The coordinator should provide the decontamination technician with a notification on priority need, especially with any turnover or add-on case. Those needs should then be checked off the list as technicians complete/fulfill them. In some instances, a scenario of “taking from Peter to pay Paul” may occur. The challenge for SP professionals is that as the instruments undergo sterilization, are cooled and then transferred to specific case carts, an immediate needed instrument may then be taken off the completed case cart that was designated for a next-day case. Sometimes, this transaction is performed without communicating a retrieved item to the SP team. Many times, the OR does have an immediate need for an instrument and, in haste, removes the first one found. Their WWW.ORTODAY.COM

we’re on instagram! sense of urgency may not allow them to properly communicate their action. The lack of communication creates several issues. While the SP team is completing the needs/priority list, they sometimes have a false sense of satisfaction that all needs were met. When the next day arrives, the OR may request the items and state that the case cart is incomplete. This creates of sense of urgency in both teams – a sense of frustration in the SPD and, possibly, a sense of mistrust between the OR and SP teams. One of many solutions may be to have the OR and SPD develop a process of incoming and outgoing products. This can be established by a tracking system and/ or the delegation of a liaison whose role is to monitor need requests and the delivery of those needed items. All requests and delivery of needed items should be documented to further promote effective communication and accountability.

Aim for Accurate Count Sheets/ Preference Cards Waste (providing instruments that weren’t needed) is an issue in many of the facilities that the advantage support team assesses. The problem, in part, lies in incorrect count sheets or count sheets that have not been updated for the surgical team or surgeon in specific services (e.g., neurology; orthopedics; cardiovascular). Again, the surgical team may open a complete tray just to retrieve one item. An example: the surgical team may need additional long hemostats

or needle holders and they know there are some in a general instrument set; they open an entire tray to retrieve just one or two items. There are several solutions for addressing instrument waste, including having a static storage area of processed general or commonly used WWW.ORTODAY.COM

instrumentation, or a service cart of commonly used items for each specific surgical service. The cart should be located in or near the surgical suites that perform that service. A tracking system that allows a surgical circulating nurse to request the extra item(s) is another approach to address the issue. The tracked request should be directed toward the liaison on the SP team and delivery should be documented. According to one Healthcare Purchasing News article, “Room for improvement in SPD could be the organization of the backup instrument area (cabinets, wall, drawers, etc.) to improve the ease of finding replacement instruments for sets that frequently return to the decontamination area of SPD missing instruments, such as towel clamps, Adson forceps and Allis clamps, just to name a few.”1

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Conclusion Categorizing instrumentation according to waste, want or need can help prioritize requests in the SPD and better meet customer and patient needs. The three categories also will help SP and OR professionals devise and implement process improvement initiatives.

Reference

1. Jelks M. An overview of lean

transformation in sterile processing. Nov. 20, 2017. https://www.hpnonline. com/sterile-processing/article/13000925/an-overviewof-lean-transformation-insterile-processing

– Angela Lewellyn, LPN, CRCST, CHL, CSPDT, serves as director of surgical services for Advantage Support Services.

ortoday.com January 2021 | OR TODAY

INDUSTRY INSIGHTS CCI

Becoming a Perioperative Nurse The Historical Context By James X. Stobinski, Ph.D., RN, CNOR, CSSM (E) ast month, I spoke to issues with recruiting and retaining staff in the operating room including supply chain management professionals, central processing technicians and perioperative nurses. All these roles are vital for the efficient functioning of an operating room suite. This month, I wish to focus more narrowly on the profession of perioperative nursing. I would like to address how nurses enter the profession of perioperative nursing and the history and evolution of their education and training. A look back at the history of nursing in this country is informative regarding perioperative nursing.

The modern history of nursing in the United States is heavily influenced by the work of Florence Nightingale. The profession of nursing in this country really begins with the Civil War which followed Nightingaleâ&#x20AC;&#x2122;s groundbreaking work with the British military during the Crimean War of 1853-1856. Nursing education in this country, until the early 1900s, was essentially an apprenticeship model where student nurses served as the labor force for early hospitals. Thus, disdain for the term apprenticeship in nursing is long standing and continues yet today. Curiously enough in these early days of professional nursing there were few employment opportunities in hospitals after graduation and many nurses entered private employment as much care was delivered in the home. To establish nursing as a profession it was necessary to strengthen and standardize the educa22

OR TODAY | January 2021

tional preparation for nurses and to base that preparation in science versus just the performance of tasks. The concentration of more sophisticated medical care in the hospital setting eventually brought employment opportunities to the hospital setting versus the earlier private employment model. The refinement of surgical techniques and the increasing complexity of surgical care was a large factor in the rise to prominence of hospitals in the American health care system. As surgery progressed, the specialty of perioperative nursing developed and became grounded in the hospital operating room. Shannon R. Olwine, in her honors thesis, refers to the writing of Linda Groah in 1990, and tells us that operating room nursing became the first recognized specialty in nursing in 1889. This key development in the late 1800s established operating room nursing as a hospital-based specialty with the employer, the hospital, playing an integral role in the education and training processes of these nurses. Operating room nurses were oriented in the workplace and the employer had a large influence on the education and training processes. These early methods still influence the profession today. For example, Isabel Hampton Robb, in her seminal 1907 text, recommended that student nurses have two months of clinical experience in the operating room. The perioperative specialty grew rapidly in parallel to advances in surgery and in 1920 the National League of Nursing Education Committee on Curriculum recommended a familiarization to the OR for nursing students, but conceded that the work required extensive training for those wishing to specialize.

Although perioperative nursing has one of the longest orientation periods in nursing there is not yet a widely accepted, core curriculum for the specialty. Even though entry to the profession may require a year of education and training there is no final examination, akin to the NCLEX which facilitates entry to practice, to mark entry to the specialty. There is a paucity of research-based evidence on the efficacy of current orientation methods and the employer still retains a central role in the assessment of perioperative nursing competency. There are ample opportunities for perioperative nursing to address these professional issues. Next month, I will speak more to possible action items in this area for perioperative nurses and revisit the term apprenticeship.

References

History.com Editors (2018). Crimean War. Accessed November 1, 2020 at: https://www. history.com/topics/british-history/crimean-war National League of Nursing Education (U.S.). Committee on Curriculum. (1920). Standard curriculum for schools of nursing: prepared by the Committee on education of the National league of nursing education (1915 to 1918) M. Adelaide Nutting, Chairman. [3d ed.]. Baltimore: The Waverly Press. Olwine, S. R. (1992). [Honors Thesis]. The Changing Roles of Perioperative Nursing. Robb, I.H. (1907). Educational Standards for Nurses: With Other Addresses on Nursing Subjects. E. C. Koeckert. James X. Stobinski, PhD, RN, CNOR, CSSM(E), is Chief Executive Officer at Competency & Credentialing Institute (CCI).

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INDUSTRY INSIGHTS

AAMI news & notes

Sterilization Leaders Pool Knowledge in Unprecedented Collaboration AMI has published a free collection of articles showcasing best practices and alternative strategies for medical device and packaging sterilization. The 11 peerreviewed articles in Industrial Sterilization: Process Optimization and Modality Changes are from experts representing a range of influential organizations within the medical industry.

The goal of this special supplement to AAMI’s journal, BI&T, is to share practices for optimization and encourage innovation. It was sponsored by Johnson & Johnson, Boston Scientific, STERIS, BD, Nordion, Medtronic and WuXi AppTec. “Helping to facilitate a sharing of sterilization knowledge between industry leaders is right in line with AAMI’s mission to ensure the effective development and use of medical devices,” said Rob Jensen, president and CEO of AAMI. “Using the best practices possible is everyone’s desire. That’s why we’re proud to publish this essential sterilization resource.” Many of these articles address the

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need to provide awareness of alternative sterilization methods and recent advancements. Others explore challenges impacting patient safety, business continuity planning and ways to improve current methodology. “It’s not a question of whether or not products are sterile, but there is always room for improvement for how we get there,” explained Emily Craven, director of sterility assurance at Boston Scientific. “It’s really about challenging ourselves to make sterilization more efficient. What we want people to think about is whether what is familiar is actually optimal.” Back in 2016, worldwide industry sterility assurance leaders met during the newly revived Kilmer Conference. There, they discussed new approaches for the sterility assurance community in areas of industrial sterilization, aseptic processing, microbiology, as well as the challenges their field currently faces. The challenges discussed during the conference identified the continuing need to collaborate. Just last year, the Kilmer sterility assurance community met again with the intent to address industry collaboration to support innovation. Prior to the conference, the leaders were polled to identify areas of concern for the industry and collaboration teams were

formed to address these topics. “The collaboration teams identified that the lack of innovation or change was often because individuals felt that there was a hurdle or roadblock that prevented action. They were not aware of the alternatives available,” said Joyce Hansen, vice president of microbiological quality and sterility assurance at Johnson & Johnson and Chair of the 2019 Kilmer Conference. “You can’t optimize or innovate a process if you don’t understand why requirements were developed in the first place … I hope these articles will start really piquing people’s interest about the science of what we do today while challenging them to think differently for the future.” Download the free Industrial Sterilization: Process Optimization and Modality Changes at www.aami.org/ sterilization-supplement-2020.

Call for Papers! Share your knowledge and make a difference in your field by submitting a paper to AAMI’s peer-reviewed journal, BI&T. Please submit a brief description of your article idea by contacting Editor-in-Chief Gavin Stern at gstern@aami.org. January 2021 | OR TODAY

INDUSTRY INSIGHTS

WEBINAR SERIES

news & notes webinars

Presenter Shares Patient Positioning Insights he OR Today webinar “Fowler’s, Prone, Supine: Patient Positioning in the Operating Room” presented by Michelle Lemmons, RN, BNS, PHN, was sponsored by Key Surgical and eligible for (1) CE credit. OR Today has been approved and is licensed to be a Continuing Education Provider with the California Board of Registered Nurses, License #16623.

Lemmons, an OR clinical educator, provided an overview, specifics, guideline recommendations and risks of the supine, prone and Fowler’s positions. Positioning patients for surgical procedures in the operating room is a complex and multifaceted duty. While mostly determined by the procedure needs, the case, surgeon and time it is vital that patient-specific information be accounted for during these cases. Lemmons detailed general considerations for surgical positioning, re-visited the published guideline recommendations and discussed risks and prevention of risks for the supine, prone and Fowler’s positions. Injury prevention and emergency preparation are some of the best tools to help patients have successful surgical outcomes. Attendees provided positive feed-

OR TODAY | January 2021

back regarding the webinar in a survey in which they were asked to comment on the overall webinar series. “Presenter was excellent and presented relevant information for endusers to do/consider when positioning patients to prevent injuries,” Manager Acute Consultant K. Murphy said. “This was phenomenal! The best OR Today webinar I’ve attended. The connections made for the preoperative interview and the positioning assessment,” Perioperative Education Program Coordinator J. Kim shared via the survey. “I really appreciate the opportunity to learn new, or validate existing, knowledge through OR Today’s webinars! The speakers are easy to understand and relate to, and info is always up-to-date and appropriate for various experience levels,” said K. Avello, RN. More than 5,000 registrations have been booked for OR Today webinars in 2020 with more sessions scheduled.

“This was phenomenal! The best OR Today webinar I’ve attended. The connections made for the preoperative interview and the positioning assessment.” – J. Kim, Perioperative Education Program Coordinator

For more information, visit ORToday. com and click on the “Webinars” tab. Thank you to our sponsor:

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January 2021 | OR TODAY

IN THE OR

market analysis

Wound Care Market to Hit $24 Billion by 2027 Staff report he global wound care market size is projected to showcase significant progress and earn $24.55 billion by 2027, according to Fortune Business Insights.

The jump is attributed to the increasing prevalence of chronic diseases such as diabetes, blood pressure and wounds that result from them, such as diabetic foot ulcers and pressure ulcers. Wound care is used for injuries that are unable to heal by themselves. If untreated, they may result in severe consequences, such as mobility issues, decreased elasticity of blood vessels and others. A recent report by Fortune Business Insights offers an overview of the market. The report states that the market value stood at $15.68 billion in 2019 and is likely to exhibit a CAGR of 6.0% between 2020 to 2027. The rising prevalence of acute and chronic diseases such as diabetic foot ulcers, pressure ulcers and others are some of the key factors promoting this market growth. This, coupled with the 26

OR TODAY | January 2021

advent and adoption of technologically advanced wound care products, will also add impetus to the market. Additionally, continuous research and development, as well as increasing investments in the launch of advanced wound care products are likely to bolster growth in the coming years. On the contrary, high treatment costs and the presence of limited or no reimbursement policies, especially in underdeveloped nations, may challenge the growth of the market. Nevertheless, the advent of bioactive therapy for treating chronic wounds is expected to create a lucrative growth opportunity for the market in the coming years. Based on segmentation by type, the advanced wound dressing segment earned 42.6% wound care market share in 2019 and emerged dominant. This is owing to the presence of a diverse product portfolio. North America earned a revenue of $6.09 billion in 2019 and emerged dominant, followed by Europe. This is on account of the increasing prevalence of acute and chronic wounds. This coupled with the presence of

well-established health care infrastructure and facilities, as well as favorable reimbursement policies by the governments of developed nations are likely to aid in the expansion of the regional market. On the other side, the market in Asia Pacific is likely to exhibit rapid growth in the coming years on account of the increasing prevalence of acute and chronic diseases as a result of the rising patient population and improving health care and medical infrastructure. A report from MarketsandMarkets also predicts growth. â&#x20AC;&#x153;The global wound care market is projected to reach $24.8 billion by 2024 from $19.8 billion in 2019, at a CAGR of 4.6% from 2019 to 2024,â&#x20AC;? according to MarketsandMarkets. The emerging economies such as India, China and Brazil are expected to provide a wide range of opportunities for players in the industry, which is driven by growing health care infrastructure, increasing diabetic population, vast population pool and increasing health care spending.

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PREVENA RESTOR AXIO•FORM The PREVENA RESTOR AXIO•FORM Incision Management System delivers negative pressure wound therapy designed to manage post-operative incisions, as well as the surrounding soft tissue envelope. PREVENA RESTOR AXIO•FORM System helps stabilize the incision and surrounding soft tissue, reduce edema, and helps enhance post-operative recovery. This is the third offering in the PREVENA RESTOR Therapy portfolio, launched in 2019, to optimize post-surgical care and expand the company’s specialty surgical offerings. Please refer to the PREVENA RESTOR AXIO•FORM System Instructions For Use for important safety information.

IN THE OR

product focus

NOTE: Specific indications, limitations, contraindications, warnings, precautions and safety information exist for these products and therapies. Please consult a clinician and product instructions for use prior to application. Rx only.

Mölnlycke

Exufiber Ag+ Exufiber Ag+ with Hydrolock technology is a sterile non-woven gelling fiber dressing that can be used to manage a wide range of exuding wounds including cavity wounds, leg and foot ulcers, pressure ulcers and surgical wounds. When it comes into contact with wound exudate, Exufiber transforms into a gel that locks in exudate and facilitates moist wound healing and ease of removal in one piece during dressing changes. Exufiber Ag+ has a rapid antimicrobial action for sustained protection against a broad range of Gram negative and Gram positive bacteria, is proven to kill 99 percent of fungus within 24 hours (in vitro) and may reduce odor.

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January 2021 | OR TODAY

IN THE OR

product focus

MolecuLight Inc.

i:X Sterile Surgical Sleeve Convenience Kit The MolecuLight Inc. i:X Sterile Surgical Sleeve Convenience Kit includes a unique disposable surgical sleeve that is fitted to neatly shroud the i:X device via an adaptor to align the optics of the i:X to the sleeve. It is made of novel, optically-clear material so it doesn’t interfere or degrade the fluorescence signal or image quality of the device. Specific applications for the MolecuLight i:X Sterile Surgical Sleeve in wound care include: • Operating room use of the i:X including for cleaning of burn wound, for surgical debridement of wounds, for application of skin substitutes and/or skin grafts, and for vascular surgical applications. • Use of the i:X where the device needs to be shielded from the patients such as in a COVID-19 ward or MRSA isolation room. Instead of performing a deep cleaning and disinfection of the MolecuLight i:X between patients, the surgical sleeve can be used instead and can be quickly replaced between patients. • Use of the i:X where the device needs to be shielded from a procedure, for example wound ultrasonic debridement where the nature of the procedure causes particles to be airborne. The MolecuLight i:X procedure has a U.S. reimbursement pathway that includes two CPT® codes (Category III) for physician work and facility payment for Hospital Outpatient Department (HOPD) and Ambulatory Surgical Center (ASC) settings through an Ambulatory Payment Classification (APC) assignment. These codes were issued by the AMA and CMS, respectively, after critical review of the large body of supporting clinical evidence and with each body recognizing the medical necessity of this procedure.

OR TODAY | January 2021

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IN THE OR

product focus

Smith+Nephew

PICO Single Use Negative Pressure Wound Therapy PICO Single Use Negative Pressure Wound Therapy is a negative pressure wound therapy system that raises the level of care: • Indicated for use on closed surgical incisions and open wounds • Manages low to moderate levels of exudate1-3 • Delivers compression-like therapy to the wound, wound margin and periwound4 • Canister-free and portable, which can help improve patient mobility and increase5-6 satisfaction rates7 • Provides therapy for up to 14 days with PICO 14 and 7 days with PICO 7/7Y • Waterproof dressing, allowing patients the ability to shower5 1. Malmsjö M. et al. Biological effects of a disposable, canisterless Negative Pressure Wound Therapy system. Eplasty 2014; 14:e15. 2. Data on File DS/18/015/R. Summary Wound Model Report for Opal PICO 7. January 2018 3. Data on file reference 1102010 – Bacterial Barrier Testing (wet-wet) of PICO dressing with a 7 day test duration against S.marcescens; Helen Lumb, February 2011. 4. Smith & Nephew January 2018. Outcomes following PICO compared to conventional dressings when used prophylactically on closed surgical incisions: systematic literature review and meta-analysis. Internal Report. EO/ AWM/PICO/004/v1. 5. Hurd, T., Trueman, P., & Rossington, A. Use of portable, single use negative pressure wound therapy device in home care patients with low to moderately exuding wounds: a case series. Ostomy Wound Management. Volume 60. Issue 3. March 2014. 6. WMP.11446.UEF/R3 Project Fairbanks Human Factors Summary Report Issue 5. G Walker, May 2017. 7. Kirsner R, Dove C, Reyzelman A, Vayser D, Jaimes H. A prospective, randomized, controlled clinical trial on the efficacy of a single-use negative pressure wound therapy system, compared to traditional negative pressure wound therapy in the treatment of chronic ulcers of the lower extremities. Wound Repair Regen. 2019 Sept;27(5):519-529.

Medi-Aire Biological Odor Eliminator The BD Medi-Aire Biological Odor Eliminator is a concentrated unique formula which chemically eliminates odors associated with urine, feces, emesis and necrotic tissue. Available in three scents – Fresh Air (A), Lemon (L) and Unscented (U).

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January 2021 | OR TODAY

CE281-60

IN THE OR

continuing education

Caring: The Essence of Nursing Lorry Schoenly, PhD, RN, CNE hether you speak to nurses or patients, the word “caring” is often used to describe the profession of nursing. In fact, the root of the word “nursing” means nurturing or caring.1 Caring is prevalent in many professions, which leads to the question: What makes caring so central to the nursing profession that it is difficult to separate it from the profession in the eyes of the public and nurses alike? That question and others relating to the “caring” in nursing have been debated by scholars for years.

Many nurse investigators have proposed that caring is the essence of practice — a belief that has dominated nursing for many years.2 Some think that nursing is a special type of human caring based on the humanistic philosophies.3 Holistic nursing speaks to the mind-body-spirit connection when caring for patients, which ensures that patients’ spiritual nature and needs are cared for as well as their cognitive and physical needs.4 Nurses who have, in modern times, become more solid in their standing as professionals may seek transcendence and, in that process, acknowledge the need to take care of themselves so they may better 30

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care for others. Nurses also believe that caring is reciprocal: Giving care to patients also benefits nurses. The belief that caring has been central to those who go into nursing has existed since before nursing was recognized as a profession or discipline.1 But what about the issues nurses face in a healthcare system increasingly concerned with costs? In looking at the economic value of nurses, one researcher noted that economic value should not overshadow the human values of caring, compassion, respect, advocacy, and social justice at the core of nursing.5 Indeed, caring in nursing remains foundational even during turbulent times in the profession.6 Family caring can be described as social support rather than caring provided by professional nurses.7 Nurse caring, as contrasted with family caring, occurs in a context in which its recipients are strangers initially. As the nurse-patient relationship unfolds, nurses and patients interact in an association from which caring attitudes and behaviors emerge.5 Nurses forge temporary relationships with patients, creating a culture in which they are welcomed. This is enhanced by respectful and caring relationships among nurse colleagues as identified in the Code of Ethics for Nurses.8

Definitions of Caring Kristen Swanson, PhD, RN, FAAN, a professor, dean, and nurse researcher on caring, defined caring as “a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and 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 36 to learn how to earn CE credit for this module.

Goal and Objectives The goal of this continuing education program is to examine aspects of nurse caring. After studying the information presented here, you will be able to: • Identify beliefs about caring practices and selected caring theories. • Differentiate between the art and science of caring. • Explain the connection of nurse caring with patient outcomes..

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continuing education responsibility.” 9 Caring/caritas is transpersonal, involves a relationship, takes place in a caring moment, and connects to love.10 Nurse caring can be difficult to define. A concept analysis of seven qualitative studies described the concept of caring in nursing from two different perspectives; the view from the nurse and the view from the patient.11 From the nurse’s point of view, caring is: • Creation of a quality relationship between nurse and patient. • Protection and support of the patient’s best interest. • Intervention by the nurse. • Influenced by the context of situation. • A way of existence, a philosophy. From the patient’s point of view, caring is: • Emotional support from the nurse. • Physical support from the nurse. • Positive personality of the nurse. Regardless of the definition of caring or the underlying theory, the context of clinical practice provides the opportunity for nurses to not only apply a science of caring to everyday nursing work but to create the art of caring with patients.

The Art of Caring Nurses are artists in distinctive and personally unique ways. Traditionally, caring has connoted a mysterious, magical ingredient of nursing art. Patients, families, and communities who interact with nurses witness and celebrate caring every day. The way nurses perform that caring is the creative and artistic part of nursing. The outcomes of those artistic caring activities may legitimately be intangible. That elusive art of caring can lead to a better outcome and health for the patient. Caring is compassionate, considerate, respectful, and concerned. Caring, like other kinds of clinical expertise, develops WWW.ORTODAY.COM

gradually. It involves the nurse’s personality, availability to the patient, and emotional support.11 One definition of art is that it is not perceived as artistic until the creative work is accepted as such by an audience. This definition can be applied to nurse caring. A nurse may celebrate the end of a caring moment and think that he or she has cared for a patient in an artistic manner. The nurse provided caring actions simultaneously as he or she performed technical skills. However, the patient who received the care did not perceive the situation as a caring one in the same way the nurse did. If the simple definition of art is accepted, then caring did not take place. For the art of caring to be realized, mutual perception of caring by the caregiver and the one receiving care must occur. Both nurses and patients benefit from caring practices.12 The example of nurses who demonstrate excellence in their caring practice encourages witnesses to emulate the skill. The disciplined, caring nurse consistently pays attention to differences among patients and unpredictability in their circumstances. Expert caring liberates nurses at the same time patients feel cared for. You can learn a lot from the best nursing practices. Some of the wisdom of nursing, passed from nurse to nurse, is located in its art. While there is both a science to be learned in nursing and an artistic expression, the two are components of nursing care at its best.

Caring Theories Many nurses have embraced the ideas of Jean Watson, PhD, RN, FAAN, in the Theory of Human Caring, which has been evolving for more than 30 years.9,13 Watson believes that caring can transform healthcare and will preserve human dignity and humanity in the healthcare system. She proposed that, at the moment, nurses and patients experience a caring transaction, caring is a moral principle, not a strategy, procedure,

or action. Caring is an intersubjective (shared feelings between nurses and patients) and interconnected human process expressing respect for the mystery of being in the world and reflected in the mind, body, and soul. Human care transactions are based on reciprocity and allow for a unique and authentic quality of presence in the world of the cared for. Caring includes the transpersonal caring relationship between nurses and patients; they are coparticipants. It takes place in the moment-to-moment encounters of nurses and patients. Nurse caring is transcendent and located in the consciousness of nurses and patients. See more on Watson’s theory at https://www.youtube.com/ watch?v=QHAVpk0LFB4. According to Watson, the outcome of nursing is to help the patient gain a greater harmony within the mind, body, and soul to generate the selfknowledge, self-reverence, self-healing, and self-care processes, along with increasing diversity.13 Harmony is realized during the human-to-human caring process and caring transactions. Watson uses the phrase “transpersonal caring” to represent what happens when nurses pay attention to the process of being human, care activity, intersubjective feelings of nurses and patients, and individuality of each nurse and patient. When nurses and patients come together in a caring moment, they transcend and connect to the human-spirit realm. Transpersonal caring generates and potentiates self-healing processes. The transpersonal caring relationship depends on a moral commitment to protect and enhance human dignity and on communication of caring by treating the person as a subject rather than an object. Watson continues to develop her caring-healing theory. She suggests that its application by healthcare providers will lead to redesign. She transformed the carative factors to clinical caritas processes and contends that there is an explicit connection between caring/caritas and love.10 January 2021 | OR TODAY

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continuing education Along with the transpersonal caring relationship and the caring moment/ caring occasion, the processes represent the elements of her theory. Based on theoretical and philosophical positions, Watson asserts that caring-healing consciousness and intentionality to care will promote healing in individuals, groups, communities, and societies. Based on studies of women’s experiences in perinatal situations, Swanson developed a theory of caring.9,14 She delineated five caring processes and their features, including: • Knowing or striving to understand an event as it has meaning in the life of the other: avoiding assumptions, centering on the one cared for, assessing thoroughly, seeking cues, and engaging the self of both (both nurses and patients participate). • Being with or being emotionally present to the other: being there, conveying ability, sharing feelings, and not burdening (nurses do not burden patients but seek to lighten patients’ burdens). • Doing for the other as he or she would do for the self if it were at all possible: comforting, anticipating, performing competently/skillfully, and protecting and preserving dignity. • Enabling or facilitating the other’s passage through life transitions and unfamiliar events: informing/ explaining, supporting/allowing, focusing, generating alternatives/ thinking it through and validating/ giving feedback. • Maintaining belief or sustaining faith in the other’s capacity to get through an event or transition and face a future with meaning: believing in/holding in esteem, maintaining a hope-filled attitude, offering realistic optimism, and “going the distance.” A systematic literature review verified these five categories of nursing processes as foundational to nurse caring, helping to validate this middle 32

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Watson’s Caring-Healing Theory13 Clinical Caritas Processes • •

• • •

•

Practice loving kindness and equanimity within context of caring consciousness. Be authentically present, and enable and sustain the deep belief system and subjective life world of self and one being cared for. Cultivate one’s own spiritual practices and transpersonal self, going beyond ego self. Develop and sustain a helping, trusting, authentic, caring relationship. Be present to and supportive of the expression of positive and negative feelings as a connection with deeper spirit of self and the one being cared for. Creative use of self and all ways of knowing as part of the caring process, to engage in artistry of caring-healing practices. Engage in a genuine teaching-learning experience that attends to unity of being and meaning attempting to stay within other’s frame of reference. Create a healing environment at all levels (physical and nonphysical, subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated). Help with basic needs, with an intentional caring consciousness, administering “human care essentials,” which potentiate alignment of the mind, body and spirit, wholeness, and unity of being in all aspects of care, tending to both embodied spirit and evolving spiritual emergence. Open and attend to spiritual, mysterious, and existential dimensions of one’s own life-death; soul care for self and the one being cared for.

range caring theory.15 The theory of Anne Boykin, PhD, RN, and Savina Schoenhofer, PhD, RN, the Theory of Nursing as Caring, assumes that people are caring by virtue of their humanity.16,1 Consistent with Watson’s theory, their theory is based on interconnectedness, collegiality, and an egalitarian model of helping that witnesses and celebrates the human person in the fullness of being. Living in a caring way is enhanced through participation in nurturing relationships with others who are caring, particularly in nursing

relationships. The nursing situation is a shared experience in which the caring between the nurse and patient enhances personhood (the state of being human). The nurse brings self as a caring person to the nursing situation and comes to know the other as a caring person. Boykin and Schoenhofer defined caring as the intentional (deliberate) and authentic (genuine) presence of the nurse with a person who is seen as living, caring, and growing in caring. The nurse is deliberately with the patient. The nurse endeavors to come WWW.ORTODAY.COM

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continuing education to know the other as a caring person and seeks to understand how that person might be supported, sustained, and strengthened in his or her unique process of living. The nurse attends to calls for caring and creates caring responses that nurture the person. Caring is a process for a lifetime in which people grow in their ability to express it and reflect on the question “How should I act as a caring person?” Sister Simone Roach looked at caring from a philosophical and theological perspective. Today, that spiritual aspect of caring can be a part of the nurse’s caring for a patient and may present as one of those caring moments. Different cultures have their own spiritual beliefs and may turn to those beliefs during the healing process. As patient receiving palliative care, his or her family may be more focused on spiritual aspects than medical procedures. After years of study, Roach concluded in the Human Act of Caring that “caring is the human act of being.”1 Madeleine Leininger’s Theory of Culture Care Diversity and Universality emphasizes the cultural and symbolic meanings that caring involves.17,18 The theory emphasizes culturally congruent care with care knowledge sensitive to the values, beliefs, and lifeways of clients for their health and well-being to prevent illness, disabilities, or death. 17,18 Leininger’s theory honors the different ways nurses can help patients in achieving positive outcomes using culturally sensitive behaviors.17,18

Research on the Science of Caring Caring research has increased, exploring such topics as the experience of caring, outcomes of caring, caring as a construct, cultural determinants of care and caring, and instruments to measure nurse caring. Because of the commitment of the International Association for Human Caring (IAHC), nursing research conferences have brought together scholars interested in studying caring and care in nursing. IAHC’s Caring WWW.ORTODAY.COM

Research Conferences, monographs and the International Journal for Human Caring, along with articles published in other journals, have been vehicles for sharing this scholarship. Many qualitative studies reveal nurses’ and patients’ experiences with caring. For example, an analysis of interviews with 21 registered nurses explored their perspectives about their own caring behaviors. Using a phenomenological approach, the researchers found the following elements of caring in the interview results:19 Caring • is person-centered • involves safeguarding the patient’s best interests • is helping the patient through nursing interventions • is intertwined with the context of the care provided The assumption that nurses are altruistic is held not only by the public but by many who seek nursing as a profession. Prompted by negative student reaction to a classroom presentation challenging the nursing profession to change its image from that of nurses as angels to nurses as competent, caring professionals, faculty at a southeastern school of nursing conducted a study of 78 (74 responded) junior-level nursing students between the ages of 19 and 48. The research was conducted to better understand the students’ motivations for entering nursing and the views and beliefs they held related to nurse competence and caring.20 Making a difference for others was identified as the strongest motivation for entering nursing, with two-thirds of the group identifying caring as an essential nursing characteristic.

Instruments That Measure Caring Over the years, researchers have constructed instruments to measure caring to substantiate its value in practice and eliminate its invisibility. Watson has provided a book that includes over 20 research instruments

to measure caring.21 Many have been successfully implemented in research to more clearly describe caring in nursing and the knowledge, actions, and attitudes that engender this concept. For example, a nurse researcher used Wolf’s Caring Behaviors Inventory-24 (CBI-24) to investigate the relationship between nurse caring behaviors and first-time mother’s confidence. This validated questionnaire consists of 24 items on a 6-point Likert-type scale and measures caring behaviors of the nurse as perceived by the patient. The study found a significant relationship between maternal confidence and the presence and support offered by the nurse.22 Another popular caring research instrument, the Watson Caritas Patient Score, was used by Brewer and Watson to measure patient perception of being cared for in 48 acute care units across the United States. This instrument is particularly suited for patient surveying as it consists of a mere five statements for patients to rate along a 7-point scale. In this study, patient perspectives on nurse caring behaviors correlated positively with publicly reported nursing communication scores.23 The researchers concluded that creating a professional caring environment enhanced patient perceptions of quality care.

Nurse Caring and Patient Outcomes It is generally accepted that the quality of healthcare services is linked to nursing care and patients’ interactions with nurses and other caregivers. As indicated in the study by Brewer and Watson, caring behaviors improve a patient’s perception of their care provided. Patient satisfaction increases when nurses care. Desmond and colleagues used a quasi-experimental research design to compare the caring behaviors of nurses who attended a one-day educational seminar on Watson’s caring theory with nurses who did not receive this education. Nurse’s January 2021 | OR TODAY

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continuing education perspective on their caring behaviors were self-evaluated two weeks prior, immediately after, and six months following the educational session. Patient outcome was measured using the Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) scores. The participant’s overall feelings of competence in adopting caring attitudes and behaviors increased immediately after the course and were sustained at the six-month measurement. In addition, patient perception of nurse courtesy and listening behaviors increased. While there are limitations to this study, including the small sample size and inability to account for the effect of other improvement initiatives in the institution, patient outcomes appear to have been affected by educating nurses about caring theory application.24 Modic and colleagues also studied the perception of hospitalized diabetic patients of caring nursing behaviors.25 They compared the perception of patients with the perception of their bedside nurses using the CBI-24 (discussed under instruments above). While patients in this study rated knowledge and skills as most frequent caring behaviors, nurse participants rated encouraging the patient to call if there is a problem and treating the patient as an individual more frequently. Both groups rated treating information confidentially as an important caring action. Duffy has created and implemented the Quality-Caring Model in acute care.26 The model helps nurses to merge caring processes of nursing with the evidence-based practice environment. Caring values, attitudes and behaviors frame the process of care, the independent patientnurse relationship, and collaborative relationships with other members of the healthcare team. The two relationship-centered encounters are thought to influence quality healthcare outcomes. The environmental culture changes, starting with the top leadership team who values human 34

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relationships among staff and patients. Nurses have adequate time for being with patients.26 Professional nursing care takes place in a caring, healing, and protective environment that is physically and aesthetically supportive. When this model was used as the theoretical basis for a qualitative survey of stroke patients following hospitalization, researchers found these patients felt cared for when nurses: 27 • Showed knowledge and skill. • Provided information and involvement. • Cared about their personhood. Nurses caring for themselves affects patient outcomes, as well. A study of hospital-employed nurses concluded that depressed nurses or those who experienced pain while caring for patients made more medication errors, experienced more patient falls in their care, and gave a lower quality of care.28 Another study used a qualitative design interviewing 21 nurses regarding their description and conception of caring. Research concluded that nurses today see their patients first as people and believe that caring is more patient-centered than in the past. While there were varied definitions of caring, the nurses used a starting point of having the patient speak about his or her illness. That information allowed nurses to create a plan of caring specific to the individual and created a bond or connection with their patients. While nursing can still be heavily task-oriented, results show nursing has evolved to allow patients to be a partner in their care. Nurses described needing to contain their frustration when the focus on measurable medical tasks kept them from performing what they considered essentials of care.19 Still, additional studies need to examine the effect of caring on healing. The caring work performed by nurses is a resource that may be a principal reason that patients are satisfied with their healthcare

experiences. While technology requires more of nurses’ time and attention, caring seems to reside within the professional paradigm of nursing.7 New studies will offer a focus on what is important in today’s challenge of incorporating caring moments into nurses’ daily routine, yet the nature of those moments will still originate with the basics. Whether a nurse must deal with communication issues, cultural barriers, or time constraints for completing procedures, the goal of good patient care remains, which means creating a connection to allow for caring moments to happen. While nurses must juggle many responsibilities, their first charge in providing good patient care is seeing patients as human beings and treating each one with respect. EDITOR’S NOTE: Zane Robinson Wolf, PhD, RN, FAAN and Theodora Aggeles, BA, RN, past authors of this educational activity, have not had the opportunity to influence the content of this version. Relias LLC guarantees that this educational activity is free from bias. Lorry Schoenly, PhD, RN, CNE, is a visiting professor with the Chamberlain University Graduate School of Nursing. Dr. Schoenly has held clinical and administrative positions in critical care, correctional nursing, continuing education, and professional development specialties.

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continuing education References 1. Smith, M, Turkel M, Wolf ZR. Caring in Nursing Classics: An Essential Resource. New York, NY: Springer Publishing; 2013.

concepts: art of nursing, presence and caring. J Adv Nurs. 2008;63(5):527534. doi:10.1111/j.13652648.2008.04622.x.

2. Wolf ZR, France NE, Lynn CE. Caring in nursing theory. Int J Hum Caring. 2017;21(2):95-108. doi:10.20467/ HumanCaring-D-17-00021.1.

13. Watson J. Core concepts of Jean Watson’s theory of human caring/ caring science. Watson Caring Science Institute Web site. https://www. watsoncaringscience.org/files/PDF/ watsons-theory-of-human-caring-coreconcepts-and-evolution-to-caritasprocesses-handout.pdf. Published 2010. Accessed April 2, 2019.

3. Letourneau D, Cara C, Gourdreau J. Humanizing nursing care: An analysis of caring theories through the lens of humanism. Int J Hum Caring. 2017;21(1):33-40. doi:10.20467/1091-5710-21.1.32. 4. O’Brien ME. Spirituality in Nursing: Standing on Holy Ground, 6th ed. Burlington, MA: Jones and Bartlett Learning Books; 2017. 5. Keepnews DM. Mapping the economic value of nursing. Washington State Nurses Association Web site. https://www.wsna.org/ assets/entry-assets/Nursing-Practice/ Publications/economic-value-ofnursing-white-paper.pdf. Updated April 2013. Accessed April 2, 2019. 6. Adams LY. The conundrum of caring in nursing. Int J Caring Science. 2016;9(1):1-8. 7. Finfgeld-Connett D. Concept comparison of caring and social support. Int J Nurs Terminol Classif. 2007;18(2):58-68. doi:10.1111/ j.1744-618X.2007.00051.x. 8. American Nurses Association. Code of ethics for nurses with interpretive statements. Silver Springs, MD: American Nurses Association; 2015. 9. Swanson KM. Empirical development of a middle range theory of caring. In: Smith MC, Turkel MC, Wolf ZR, eds. Caring in Nursing Classics: An Essential Resource. New York: Springer; 2013: 211-221. 10. Watson J. Caring Science as Sacred Science. Philadelphia, PA: FA Davis; 2005. 11. Drahasova L, Jarsova D. Concept caring in nursing. Cent Eur J Nurs Midw. 2016;7(2):453-460. doi:10.15452/CEJNM.2016.07.0014. 12. Finfgeld-Connett D. Qualitative convergence of three nursing WWW.ORTODAY.COM

14. Lillykutty MJ, Samson R. Insights from Kristen M Swanson’s theory of caring. Asian J Nurs Educ Res. 2018;8(1):173177. doi:10.5958/23492996.2018.00036.8. 15. Kalfoss M, Owe J. Empirical verification of Swanson’s caring processes found in nursing actions: systematic review. Open J Nurs. 2015;5:976-986. doi:10.4236/ ojn.2015.511104. 16. Boykin A, Schoenhofer S. Nursing as Caring: A Model for Transforming Practice. http://www.gutenberg.org/ files/42988/42988-pdf.pdf. Published June 20, 2013. Accessed April 2, 2019. 17. Leininger MM, McFarland MR, eds. Culture Care Diversity and Universality: A Worldwide Theory of Nursing. 2nd ed. Sudbury, MA: Jones & Bartlett; 2006. 18. Utley R. Care and caring frameworks. In: Utley RA, Henry K, Smith L, eds. Frameworks for Advanced Nursing Practice and Research: Philosophies, Theories, Models, and Taxonomies. New York, NY: Springer Publishing Company; 2018: 51-59. 19. Andersson EK, Willman A, SjostromStrand A, Borglin G. Registered nurses’ descriptions of caring: a phenomenographic interview study. BMC Nurs. 2015;14:16.

21. Watson J. Assessing and Measuring Caring in Nursing and Health Science. 2nd ed. New York, NY: Springer Publishing Company; 2009. 22. Mott B. Measurement of Swanson’s theory of caring using primiparous mothers. Int J Hum Caring. 2016;20(2):97-101. doi:10.20467/1091-5710-20.2.96. 23. Brewer BB, Watson J. Evaluation of authentic human caring professional practices. J Nurs Admin. 2015;45(12):622-627. doi:10.1097/ NNA.0000000000000275. 24. Desmond ME, Horn S, Keith K, Kelby S, Ryan L, Smith J. Incorporating caring theory into personal and professional nursing practice to improve perception of care. Int J Hum Caring. 2014;18(1):36-44. doi:10.20467/1091-5710-18.1.35. 25. Modic MB, Siedlecki SL, Quin Griffin MT, Fitzpatrick JJ. Caring behaviors: perceptions of acute-care nurses and hospitalized patients with diabetes. Int J Hum Caring. 2016;20(3):160-164. 26. Duffy JR. Quality Caring in Nursing and Health Systems: Implications for Clinicians, Educators, and Leaders. 2nd ed. New York, NY: Springer Publishing Company; 2013. 27. Davidson JE, Baggett M, ZamoraFlyr MM, et al. Exploring the human emotion of feeling cared for during hospitalization. Int J Caring Sciences. 2017;10(1):1-9. 28. Letvak S. Overview and summary: healthy nurses: perspectives on caring for ourselves. Online J Issues Nurs. 2014; 9(3). doi:10.3912/OJIN. Vol19No03ManOS.

doi:10.1186/s12912-015-0067-9. 20. Rhodes MK, Morris AH, Lazenby RB. Nursing at its best: competent and caring. Online J Issues Nurs. 2011;16(2). doi:10.3912/OJIN. Vol16No02PPT01. January 2021 | OR TODAY

Clinical Vignette Mrs. Dwyer had a reputation for being anxious and demanding. When the nurse went into her room at midnight to assess her, she was out of bed and sitting in the chair. She complained of being short of breath although her pulse oximetry was fine, and her vital signs were within normal limits for her. The nurse left the room and consulted with her peers. They quickly assured her that “she always says this,” “she is fine,” and “this is normal for her.” Mrs. Dwyer was still complaining of many things at 12:45 a.m. and demanded the nurse call her family physician at home to come in, at which point several other nurses came in to help manage her care. They explained that her physician would be sleeping now, and she would be fine until he came in to see her in the morning. She continued to insist that she could not breathe, yet her vital signs were stable. 1. What behavior of the nurse would have illustrated a caring response? a. Believing the patient’s complaints. b. Administering her medications. c. Listening to the other nurses’ judgments. d. Assuming the complaints were unfounded. 2. Mrs. Dwyer’s nurse was uncertain that her complaint of shortness of breath indicated she was in danger. Nevertheless, she returned to check on her frequently. What caring approach does the nurse’s behavior demonstrate? a. Establishing a relationship. c. Showing discomfort. b. Demonstrating sensitivity. d. Being present. 3. Another nurse came into Mrs. Dwyer’s room and told the patient, “You are all right; you’re fine now.” How could Mrs. Dwyer interpret this nurse’s care of her? a. Lack of sensitivity. c. Bored with her anxiety. b. Temporary response. d. Inadequate connection. 4. Soon thereafter, Mrs. Dwyer’s cardiac monitor went from a sinus tachycardia to asystole. She experienced a cardiac arrest; attempts at resuscitation failed. What does this outcome illustrate? a. Failure of rescue teams demonstrates caring by hospitals. b. Caring involves a multifaceted effort aimed at safety. c. Caring predicts effective nurse-patient relationships. d. Nurse caring may be linked to safety and quality.

Clinical VignettE ANSWERS 1. Answer: A, The healthcare provider can demonstrate a caring process by maintaining belief that the symptoms were indicative of a serious change in the patient’s status and respecting the patient’s complaints. 2. Answer: D, Returning frequently to check on a patient is a caring behavior that illustrates being present for a patient during her time of vulnerability. 3. Answer: A, Noncaring behaviors are interpreted by patients as insensitivity and indicate a lack of professional caring. 4. Answer: D, Nurse caring affects patient outcomes. 36

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CE281-60

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

Deadline Courses must be completed by 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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g n i t n e v e Pr

Patient

Falls BY DON SADLER

OR TODAY | January 2012

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HEALTH

espite efforts to reduce their frequency in hospitals and in the OR specifically, patient falls remain a serious problem for health care facilities. It’s estimated that somewhere between 700,000 and one million patients in the U.S. experience a fall in the hospital each year. Patient falls are obviously dangerous for patients, potentially leading to bruises, fractures, skin lacerations and other forms of trauma, as well as extended lengths of hospital stay for patients. The financial impact of patient falls is also significant – the cost of these falls averages $30,000 per hospital stay or $50 billion total per year. And as of 2008, the Centers for Medicare & Medicaid Services (CMS) no longer reimburses hospitals for certain types of traumatic injuries that occur while a patient is in the hospital — many of which could result from a fall. According to David Taylor, MSN, RN, CNOR, the president of Resolute Advisory Group LLC, while falls in the operating room are relatively rare, they do occur. “OR staff can prevent harm to their patients if they understand how these incidents occur and implement safety precautions to prevent them before they happen,” he says. Taylor cites a 2018 study published in the AORN Journal that reviewed 22 OR patient falls between 2010 and 2016 within the Veterans Health Administration. The majority of the incidents (68 percent) involved patients falling from the OR bed while 27 percent happened during the transfer of the patient to or from the OR bed, according to the study. Meanwhile, a review of The Joint Commission’s Sentinel Event database indicates that the main causes of patient falls are inadequate assessment, miscommunication, protocol deviations and deficiencies in the physical environment. “There are any number of reasons why a fall could occur in the OR,” says

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Taylor. “These include tilting or malfunctioning of the OR bed, problems with safety restraints or locks on the gurney wheels, inadequate patient sedation and poor communication among OR staff.” According to Holly Wirth, MSN, RN, SCRN, clinical director, neurosciences on the Inova Fairfax Medical Campus in Falls Church, Virginia, having a surgical procedure typically increases a patient’s risk of falling. “Medications, anesthesia and being connected to equipment are all factors that can lead to a patient falling down,” she says. “Patients may walk into our facilities independently, but after having a procedure, they may feel unsteady, dizziness or weak,” Wirth adds. “Educating patients and their care companions on what to expect post-procedure or during their hospital stay helps create a safe environment for recovery.”

Being Proactive About Fall Prevention Darla Ceppi, who is the clinical director of the orthopaedic/spine unit on the Inova Fairfax Medical Campus in Falls Church, Virginia, says that her facility is very proactive when it comes to falls prevention. “We ambulate our patients on the day of surgery,” she says. “And we’re aggressive with mobilization – all staff are trained on how to move the patients.” When patients are admitted to the unit, Ceppi and her team discuss the falls contract with them, which encourages patients to call for assistance every time they want to get up. “We also have fall mats by the bed in every room in case there is a fall to hopefully decrease injury,” says Cep-

January 2012 | OR TODAY

pi. “And at shift change, consideration has been transferring patients to and from the every high-falls patient is given to the emotional operating table.” discussed so all staff are and behavioral impacts of aware and can help as patient falls. “After a fall, I A Comprehensive Fall Prevention needed.” have observed that patients Program Taylor stresses the often demonstrate deceased The Inova Fairfax Medical facility importance of eliminatself-confidence in gait and a Holly Wirth, MSN, RN, has implemented a comprehensive, ing distractions in the OR SCRN, clinical director, reluctance to release railings evidence-based patient fall preventhat can lead to patient or support devices,” he says. neurosciences tion program in which nurses assess falls. “Noise and loud mu“Or worse, I’ve seen papatients regularly using the Johns sic, for example, can keep tients frantically Hopkins Fall Risk Assessthe team from being focused on the grasp at anything to hold ment Scale to determine patient,” he says. on to, becoming unstable their level of falling risk “Also avoid irrelevant conversaand falling again,” Arndt during their stay. “Interventions that can keep team members adds. “The fear of a tions are then tailored to from anticipating next steps,” Taylor repeat fall can represent each patient’s individual adds. “Using electronic devices for a true barrier to recovery needs and risk factors,” says patient care is expected but using and mobility.” Wirth your phone to text someone durWirth concurs: “PsyNurses and care providers ing a procedure is not. Neither is chologically, patients who Brian Arndt, MBA, on the Inova Fairfax Medical surfing the Internet during a surgical fall may feel scared and BSN, RN, CNML Campus support fall prevenprocedure.” anxious,” she says. “They tion through a multi-faceted Taylor was once asked to review may lose their sense of feelapproach that consists of the followa medical malpractice suit in which ing safe, which may have a lasting ing: various aspects of a patient fall were impact on them.” • Patient and family education; being evaluated to determine who Taylor believes that training and • Purposeful rounding on patients was liable for the patient’s injuries. education are among the biggest to anticipate needs; “The phone records of the aneskeys to preventing patient falls, along • Creating a safe patient care envithesia provider and circulating nurse with fall risk screening tools. “So is ronment; and were subpoenaed,” Taylor says. “And an assessment of your OR and hos• Embracing fall prevention techthe records revealed that they were pital equipment,” he says. “Adequate nology such as bed exit alarms both using their phones throughout safety equipment, proper positioning and remote video monitoring. the case, sending and receiving text equipment and technology can be “We use AVASYS, which is a messages, searching the Internet and simple solutions to patient safety and remote form of monitoring,” says playing games.” fall prevention.” Ceppi. “A small camera is placed in In addition, Taylor stresses the the patient’s room that sounds an importance of never underestimating Getting More Engaged alarm when the patient attempts to the size of patients who are being Brian Arndt, MBA, BSN, RN, get up. For patients who are nontransferred. “I have seen near misses CNML, who is the director for heart directable with AVASYS, we put a with every patient type, from infants and vascular service for University sitter in the room.” Health, San Antonio, says that he has to morbidly obese patients,” he says. “Our goal is to send each panoticed an increase in fall prevention “Be sure you have the right people in tient home better than when they place for patient transfers, and never measures and stratification of fall arrive at our facilities,” says Wirth. try to transfer a patient by yourself. risks in hospitals. “Preventing harm to patients while There’s safety in numbers.” “The alarms are getting more sothey’re on our campus – including “Awareness of the effects of phisticated and the health care teams patient falls – is a key component are more engaged in preventing falls,” sedation and blocks is critical in of our organization’s mission, vision the perioperative environment, says Arndt. “Although we are a long and values.” especially in an elderly population,” way from the goal of zero patient “All health care providers play falls, I honestly believe we’re heading adds Arndt. “It’s vital to be familiar a pivotal role in preventing patient with all of the equipment in the OR the right way.” falls and the injuries that can be and vigilant when positioning and Arndt believes that not enough caused by them,” adds Taylor.

40 OR TODAY | January 2012

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SPOTLIG Nechami Brilliant BSN, RN, Nurse III/Perioperative Instructor, Neuro/Spine OR Johns Hopkins Hospital, Baltimore, Maryland

By Matt Skoufalos

Nechami Brilliant has always put family before everything else in her life. A registered nurse and perioperative instructor, in the neuro/spine operating room at Johns Hopkins Hospital, in Baltimore, Maryland, Brilliant began her health care career as a doula. For 15 years, she guided other women through childbirth while raising her own kids at home. And every time she returned home from coaching another new mother through labor and delivery, she told her husband how much she thought she could become a nurse. “Eventually, he said, ‘Just go for it,’” Brilliant said. “I quit and went to school full-time.” When she was wrapping up her education, however, labor and delivery jobs were difficult to land, so Brilliant applied to any and every nursing position to which she could send a resume. The Baltimore native stopped just short, however, of daring to aim as high as Johns Hopkins University, the worldrenowned medical institution in her own backyard. “I had some interesting interviews, but nothing stuck,” Brilliant said. “I’d applied to other local hospitals but avoided Johns Hopkins because I thought it was over my head. My friend convinced me to apply, telling me they train new nurses. Within 24 hours I had an interview for the neuro and spine surgical unit.” In short order, Brilliant went from wonder42

OR TODAY | January 2012

ing if she’d be good enough to land a job in a premier medical setting to training for one of the most intense surgical units to which she could be assigned. The six months she spent in orientation for the operating room began a process of personal and professional growth that she said was among the most transformative of her life. “When I came into the job, I was on the quieter side,” Brilliant said. “I was very caring and very compassionate, but I didn’t have a lot of the professional skills, the communication skills that I learned on the job. It helped me blossom.” Throughout her orientation, Brilliant learned both the circulating and the scrubbing roles simultaneously. Following the in-house motto, “you see one, you do one, and then you teach one,” she then began precepting new nurses after about 18 months on the job. Spending two days in the unit and two days in the perioperative education offices, Brilliant discovered that she enjoyed teaching as much as learning. “I had already started to grow my own backbone and communicate with the surgeons, nurses, and anesthesiologists, and when they needed help in the education office, I started educating new nurses in the hospital,” she said. “They would pull me off the floor to help in the classroom, WWW.ORTODAY.COM

GHT ON and I became part of the team orienting new nurses.” Teaching fulfilled Brilliant in the same way that her career in labor and delivery coaching did. In her new role as a nurse educator, she relied upon the underlying principles that had allowed her to mentor and develop her clients’ comfort with childbirth techniques to help new nurses find the fullness of their potentials as well. “I love helping people succeed and helping people grow and mature like I did,” Brilliant said. “I know what they’re experiencing, and I feel like I can speak and connect with them and help them with the process.” Beyond learning from her instructors at Johns Hopkins, Brilliant also had the unlikely opportunity to apply the knowledge she’d acquired there to save one of their lives. Earlier this spring, as one of her educators was leaving for the day, she called Brilliant to say she thought she needed to go to the emergency room. “I ran to the other side of the hospital with a wheelchair, and by the time I had gotten to her, I could see that something was wrong,” Brilliant said. “Her face was drooping, and she was throwing up terribly. I said, ‘I think you need a lot more than the E.D.” The number for the hospital rapid response unit had been burned into her brain from orientation, and faster than Brilliant could believe, the team was there to perform a stroke assessment. She accompanied her WWW.ORTODAY.COM

colleague to the emergency room before returning to the office to call her coworker’s family. This all happened during the height of the novel coronavirus (COVID-19) pandemic, and visitors were not allowed into the hospital. That made the circumstances all the more challenging, but thankfully, the rapid intervention that Brilliant had helped provide allowed her colleague to survive the stroke without any lingering deficits. Within 48 hours, she was discharged to her family. Throughout the entire experience, Brilliant leaned on the education she’d received at Johns Hopkins to advocate for her coworker as fiercely as she does for her patients. “I have worked very hard on myself to be a big patient advocate and to speak up and speak out when there’s an issue going wrong,” she said. “I’m also a very reliable team player; when surgeons come into the OR, they know that I’ve got their back.” Brilliant hopes to parlay her experience as an educator to teach the next generation of nurses at the community college level or online. “It’ll take me a few years, but I’ll get there,” she said. “I really love encouraging the growth of people, so I hope I’ll be able to give back some of what I was given in the schools that I attended.” Among the wisdom Brilliant seeks to impart upon new nurses, it’s to seek out and take advantage of mentors who will encourage your growth, be open to learning, and accept constructive criticism as an opportunity to develop personally and professionally “instead of feeling that you’re not there yet. “I’m lucky that I’m surrounded by nurses who are wiser and phenomenal mentors, in addition to people who are here who’ve moved on and have really encouraged my growth,” she said. January 2012 | OR TODAY

OUT OF THE OR fitness

Balance Your Workouts, Balance Your Life By Miguel J. Ortiz hen most people think of

W balance exercises, they

tend to imagine a yoga class with people standing on one foot. It isn’t necessarily a motivating image. The way I see it, we’re thinking about it all wrong. Balance doesn’t have to be slow moving or done in specific settings. We are using a lot more balance in our day-to-day life than we think, and it can easily be applied to a lot of different exercise routines. The greatest attribute to balance is that it requires a great deal of concentration. Science has shown that elevated focus comes with physical benefits. So, if you ever feel foggy headed or a general lack of focus you may want to add balance exercises to your routine. Adding balance movements to a workout is not difficult. One can start with a simple warm-up like jumping rope. The light repetitive balance required to properly push off the balls of your feet and have enough coordination to repeat44 OR TODAY | January 2021

edly jump at the same height to control the exercise can create a higher sense of focus. Another great warm-up for legs is a single leg touch down where you stand on one leg and try to touch that same foot with your opposite hand. This is a great leg and core warm-up exercise that requires proper balance and coordination. It also keeps one’s attention. Try three sets of 10 reps per side. Some good upper body moves include a plank hold with an alternating arm raise. The balance provided every time you lift up an arm adds to shoulder strength. Core focus is a great way to spice up your plank holds. Again, there are plenty of areas where you can add balance. If you’re already doing push-ups you can do 10 reps where you pick up one foot (five for each side). This exercise continues the focus on strength with more core focus. Another great way to utilize balance is to do cone or ladder drills. First, when performing these types of drills, it is important to maintain your center of gravity while moving through. To add to it, the faster you become at doing these movements the more core control and balance is required. So, in order to move your

body quickly through space more core balance is needed to maintain proper form. A good example is a step class. We have all seen step classes, but if you want you can also use it for quick feet drills to add some cardio or balance and strength. An example is a lunge to step up and balance with dumbbells. Either way, doing exercises that require a form of coordination or focus ultimately also work on balance. Remember balance doesn’t always have to be slow, but it definitely requires control. So, whether you’re doing some strength moves like a single leg shoulder press or mixing it up with some footwork drills, keep your breathing and focus dialed in and have fun progressing your balance. 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 EQ factor

Identifying Behavioral Styles By daniel bobinski, M.Ed. earning about behavioral styles is extremely helpful for creating better teamwork and increased productivity. As a bonus, behavioral styles are easy to learn and only four main styles exist.

Naturally, everyone is a blend of the four styles, but usually one or two stand out as dominant. Once we identify someone’s preferred, or dominant, style, we can learn how to adapt our approach when talking with that person to optimize communication. That said, it’s always important to learn about ourselves first. If we don’t know our own style, it’s difficult to adapt adequately to someone else’s style.

How to Identify the Four Styles Let me ask you to imagine a circle. Now imagine a vertical line that bisects the circle, creating two equal halves. Think of that line as a spectrum on which we can create plot points. At the top we can plot people who are strongly task focused, and at the bottom we can plot those who are strongly focused on people. Between the top and the bottom are gradients. Someone scoring in the middle would be equally focused on tasks and people, while someone’s scoring between the middle and the top would be focused on tasks 75% of the time and people 25% of the time. Conversely, someone scoring between the middle and the bottom would favor people 75% of the time and tasks 25% 46

OR TODAY | January 2021

of the time. Again, think gradients. Since self-awareness is always the best starting point, estimate where you think you would score on this line. Now imagine a horizontal line that divides the circle into top and bottom halves. On the far left of that line is the plot point for people who are quite reserved and prefer taking their time when faced with high risk decisions. On the far right of that line is the plot point for bolder personalities who are quite comfortable making high-risk decisions quickly. As before, the middle of the horizontal line would be for people who are equally balance between those two descriptions, and the gradients continue in each direction as before. Because these two lines are perpendicular, we have created four quadrants on our circle. How you score yourself on those two lines (Task v. People; Reserved & Low-Risk v. Bolder & High Risk) determines your core behavioral style.

Four Core Behavioral Styles Task & Bold/High-Risk: When people in this quadrant they see a problem, they strive to resolve it quickly. These people are often known for taking initiative and meeting deadlines. People & Bold/High-Risk: People in this quadrant tend to have fast, creative minds. They often think outside the box and are inspired by a shared vision and future possibilities.

People & Reserved/Low-Risk: People in this quadrant prefer stable, predictable situations. They tend to be supportive and loyal. Task & Reserved/Low-Risk: People in this quadrant tend to be careful and meticulous. They prefer analyzing concepts in a logical framework and taking time to think through decisions. In the coming months we’ll take a deeper dive into each of these styles, including their value to the team and how to communicate best with each style. Daniel Bobinski, M.Ed. is a best-selling author and a popular speaker at conferences and retreats. For more than 30 years he’s been working with teams and individuals (1:1 coaching) to help them achieve excellence. He was also teaching Emotional Intelligence since before it was a thing. Reach Daniel through his website, MyWorkplaceExcellence.com, or his office: 208-375-7606.

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OUT OF THE OR health

Study: Brain Games May Improve Recovery from Surgery new study by led by researchers at The Ohio State University Wexner Medical Center and The Ohio State University College of Medicine finds that exercising your brain with “neurobics” before surgery can help prevent post-surgery delirium.

Essentially, your brain can be prepared for surgery, just as the body can, by keeping your mind active and challenged, according to findings published online in the journal JAMA Surgery. To study the effects of neurobics to prevent delirium, researchers gave 268 patients over the age of 60 an electronic tablet loaded with a brain game app. Patients were asked to play one hour of games per day in the days leading up to a major surgery requiring general anesthesia. “Not all patients played the games as much as we asked, but those who played any at all saw some benefit,” said Dr. Michelle Humeidan, an associate professor of anesthesiology at Ohio State College of Medicine Wexner Medical Center and first author of the study. “Patients who 48

OR TODAY | January 2021

practiced neurobics were 40% less likely to experience postoperative delirium than those who did not, and the results improved the more hours they played.” The electronic tablet-based preoperative cognitive exercise targeted memory, speed, attention, flexibility and problem solving functions. Those who played five to 10 hours cut their risk by more than half, and those who played the prescribed 10 hours or more had a 61% reduction in delirium rates compared to the control group. In recent years, doctors have embraced “pre-habilitation” for patients leading up to surgery, which may include exercise, a healthy diet and controlling any chronic conditions. However, none of those interventions address postoperative delirium, a complication that is especially common in older patients and causes mental confusion leading to longer hospital stays, slower recoveries and even an increased risk of death. “Our intervention lowered delirium risk in patients who were at least minimally compliant. The ideal activities, timing and effective dose for cognitive exercise-based interventions

to decrease postoperative delirium risk and burden need further study,” said co-author Dr. Sergio Bergese, a professor of anesthesiology and neurological surgery at Stony Brook University, who was working at Ohio State Wexner Medical Center in 2015 when the study started. Future research will explore exactly how brain games impact mechanisms in the brain, and how much patients should practice neurobics to reap the full benefits. “Using the app was ideal for this study because we could easily track how long and how often patients were playing,” said Humeidan, who’s also an anesthesiologist at Ohio State Wexner Medical Center. “But things like reading the newspaper, doing crossword puzzles or anything you enjoy to challenge your mind for an hour each day may improve your mental fitness and help prevent delirium as well.” This study also involved Ohio State researchers Joshua-Paolo C. Reyes, Christopher M. Nguyen, Elizabeth Sheridan, Alix Zuleta-Alarcon, Andrew Otey and Mahmoud AbdelRasoul, along with Cory Roeth of Wright State University. WWW.ORTODAY.COM

OUT OF THE OR nutrition

Resilience: Your Biggest Opportunity By Kirsten Serrano ealth is probably at the top of your mind during this pandemic, but have you taken the time to really define what health is? It is not just the absence of illness. You are not healthy simply because you are not sick. Health is resilience. It is having the ability to bend and not break. The stressors are going to come and 2020 brought an avalanche. Working in the health care system, you probably have been stressed in ways you may not have been able to imagine before. True health is having the resilience to deal with the onslaught and not crumble. Think of resilience like keeping air in your life raft. Without it, the next wave, even a small one, may drag you under. Keeping your life raft fully inflated means you can enjoy the ocean as long as possible.

Resilience is something you construct and that is a very good thing. Here’s why: you have opportunities all day every day to add to or deplete your resilience. You have so much control but may not realize it. It is very human WWW.ORTODAY.COM

of us to draw straight lines between cause and effect. Saying that you have insomnia because your mother had it, is not only an oversimplification, but one that removes you from the equation. It is surrender. Most health challenges are multifactorial, and we are the greatest common denominator. That kind of power is overwhelming but also empowering. Food is a powerful tool to build (or deplete) resilience. I know what you may be thinking but believe me. Food can be good for your body and brain and still be delicious! Really using food to your advantage is a type of literacy most of us were not taught. Building health is about nutrition knowledge and improving habits. During the pandemic, there has been a huge increase in interest in eating for immune support, but also in gardening and cooking. Food is, rightfully so, front and center right now. I encourage you to take a bit of time and make a list of ways to improve your resilience. They can be sweeping changes or tiny. It all matters. If you want some help, you can get a PDF that will get you thinking at SmallWonderFood.com/resilience. Really take the time to brainstorm ways

you can be more resilient as well as what is draining your resilience (poking holes in your raft.) Once you have a list, do not give into overwhelm. That is critical. Overwhelm is the roadblock that so often stops us in our tracks. Remember, the whole point is that small changes add up. It is not about perfection; it really is about self-care in the truest sense. Look at your list, choose some easy wins and start there. Be kind to yourself. Over time, you will feel a lot more buoyant. Come back to this column every month for ways to use food to build resilience and be the healthiest you. – “”

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.

January 2021 | OR TODAY

OUT OF THE OR recipe

Chorizo Ragu with Cheesy Toast INGREDIENTS: • 3 bolillo-style rolls or 1 long baguette

Recipe

• 2 tablespoons olive oil

the

• 1 yellow or white onion, chopped • 2-3 carrots, chopped • 1⁄2 teaspoon salt • 6 cloves garlic, divided • 8 ounces white or cremini mushrooms, chopped • 2 tablespoons tomato paste • 1 tablespoon dried oregano • 1 teaspoon ground cumin • 1 1⁄4 pounds ground beef • 1 package (9 ounces) Cacique Pork Chorizo • 1 can (28 ounces) crushed or pureed tomatoes • 6 tablespoons unsalted butter, softened • 9 tablespoons Cacique Crema Mexicana, plus additional for serving • 1 1⁄2 cups crumbled Cacique Ranchero Queso Fresco

By Family Features

50 OR TODAY | January 2021

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Uncovering the Top Mexican Food Trends for 2021

OUT OF THE OR recipe

By Family Features any families constantly search for meal inspiration, and one of the best ways is to look toward trendy tastes for new options to add to the menu.

One of the country’s top Hispanic food brands, Cacique, tapped culinary experts and chefs Aarón Sánchez, Bricia Lopez and Santiago Gomez to curate the third annual “What’s Next in Mexican Cuisine” trends forecast uncovering popular flavors, techniques and dishes to expect in the coming year. “One way we can all honor the impact of Latin culture in America is through food,” Sánchez said. “One easy step you can take to connect with a culture is by using authentic ingredients, like in this Chorizo Ragu with Cheesy Toast, which uses three staple Mexican ingredients – queso fresco, crema Mexicana and chorizo. It’s inspired by my prediction that Mexican comfort foods and deep, rich sauces made from scratch will rise in popularity.” Consider these top Mexican food trends for 2021 according to Sánchez, Lopez and Gomez along with findings from a survey conducted by OnePoll on behalf of Cacique: • The bread baking craze of 2020 will now include homemade corn and flour tortillas with

Chorizo Ragu with Cheesy Toast Recipe courtesy of chef Aarón Sánchez 1. Preheat oven to 400 F. Halve bread lengthwise. 2. In heavy-bottomed pot, warm olive oil over medium heat. Add onions, carrots and salt then cook, stirring occasionally, until vegetables just start to soften, 3-4 minutes. Mince 2 garlic cloves and add to pot with mushrooms; cook about 3 minutes. 3. Use spoon to push vegetables to edges of pan then add tomato paste, oregano and cumin to center of pan; sauté until fragrant, 1-2 minutes. 4. Increase heat to high and add beef and pork chorizo. Break meat up with spoon but don’t overstir. When beef is no longer pink, pour in tomatoes and bring to simmer. Decrease heat to mediumhigh and let simmer, stirring occasionally.

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•

55% of Americans reaching for masa harina, flour and tortilla presses to make their own. Americans have a thirst for dehydrated chiles with varieties ranging from pasillas to anchos set to become more popular in American kitchens. Dried chiles, beans and cheeses such as queso fresco will find their way into more American kitchens as people adopt a “from scratch” approach and back-to-basics techniques. Coziness, meet Cozumel as Mexican comfort foods reign supreme and people gravitate toward nostalgic “homemade” style favorites like enchiladas. Get ready to dive into deep, rich sauces, including mole, which will continue to grow in popularity. Salsa macha will share the spotlight thanks to exploration of the breadth of salsa varieties that exist within Mexican cuisine. Food exploration will satisfy Americans’ wanderlust as 55% plan to travel less in 2021, and the same percentage report they’re looking to learn the stories behind famous Mexican recipes.

To find more trend-inspired recipes, visit caciqueinc.com.

5. While ragu simmers, use fork to mash or whip butter with crema until smooth. Mince or finely grate remaining garlic cloves then stir into crema mixture. 6. Spread crema mixture evenly over bread, trying to cover as much area as possible. Sprinkle crumbled queso fresco all over and place bread on rimmed baking sheet, cheese side up. Toast 4-5 minutes until cheese is melted and bubbling. Finish under broiler 30-60 seconds for deeper browning, if desired. Cut bread into individual portions. 7. After about 20 minutes of simmering, ragu should thicken and flavors meld. Swirl in additional crema then serve ragu in bowls with cheesy toast or ladle over pieces of toast.

January 2021 | OR TODAY

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s in you. Resolve to lie s es in p p ha d an “Your success le all form an invincib sh u yo d an y jo ur keep happy, and yo lties.” host against difficu – Helen Keller

OR TODAY | January 2021

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The News and Photos

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PAIN TREATMENT A CHALLENGE IN ALZHEIMER’S DISEASE

he treatment and management of pain in people with Alzheimer’s disease (AD) can be a challenge due to problems in communication and uncommon symptoms of pain. Opioid painkillers are widely prescribed, but not without adverse effects. Finding the best course of treatment to alleviate pain in people with Alzheimer’s disease is a complex and multifaceted issue. One recent contribution to increasing our understanding of the big picture around AD, pain and painkillers is a PhD thesis by Researcher Aleksi Hamina, MSc (Pharm.), at the University of Eastern Finland. Using data from nationwide health care registers, he has studied the use of opioids and other painkillers in more than 70,000 people diagnosed with AD in Finland. “Treating pain in older adults is a massively important issue, which will become even more important in the near future. Analgesics are very widely used, but the evidence on their harms and benefits is not as strong as we would hope for. This goes even more for people with cognitive disorders, such as AD, and there really isn’t enough research on how and which analgesics are being used,” Hamina says.

Many faces of pain

Pain is commonly reported by older people regardless of whether they have Alzheimer’s or not. However, AD makes things more complicated, as there are frequent problems in communication and people may express their pain through behavioural and psychiatric symptoms. Indeed, antipsychotics, anti-anxiety drugs and sleep-inducing drugs are often prescribed to people with AD, sometimes in response to their symptoms of pain. “We found that when people with AD were prescribed an opioid analgesic, use of antipsychotics and benzodiazepine drugs began to decrease. This could indicate better management of their pain, although it is impossible to know for certain from the data we used,” Hamina points out.

Use of opioids is common and often long-term

People with Alzheimer’s disease are prescribed an opioid almost as frequently as people without AD. There are, however, differences in how opioids are used. Pills are often replaced by opioid skin patches, whose effect can last up to several days. Long-term use is also common in people with AD: once an opioid is started, more

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than 30% continue using them for six months or more. “Long-term use of opioids can be problematic, as adverse effects may occur. In any case, regular assessment of pain and opioid use is important in all patients, those with and without cognitive disorders alike,” Hamina says.

Opioid painkillers increase pneumonia risk

While opioids may alleviate pain and other possible pain induced symptoms in people with AD, they also increase the risk of pneumonia by around 30%. Strong opioids such as oxycodone and fentanyl increase the risk most, but an increased risk was also found among those using buprenorphine, tramadol or codeine. “Opioids weaken the cough reflex and increase sedation, possibly explaining the increased risk of pneumonia,” Hamina says. Treating pain in older people with drugs, especially long-term, is always a balancing act. “On one hand, pain should be treated, but on the other hand, all drugs have adverse effects. Non-pharmacological methods should be preferred and also facilitated on a system level. If opioids are used, low initial doses and careful monitoring should follow. Research should focus on investigating the safest and most effective ways of treating pain in individuals with cognitive disorders,” Hamina concludes. – Aleksi Hamina’s PhD thesis is available for download at: https://epublications.uef.fi/pub/urn_isbn_978-952-613267-9/urn_isbn_978-952-61-3267-9.pdf

January 2021 | OR TODAY

INDEX

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ALPHABETICAL Action Products, Inc.……………………………………… 37

Encompass Group………………………………………………15

Molnlycke Health Care…………………………………… BC

AIV Inc.…………………………………………………………………13

Healthmark Industries Company, Inc.……………41

OR Today Webinar Series……………………………… 45

ALCO Sales & Service Co.……………………………… 25

Jet Medical Electronics Inc………………………………19

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

ASCA………………………………………………………………… 25

MD Technologies Inc.……………………………………… 10

TBJ Incorporated………………………………………………… 4

Cygnus Medical…………………………………………………… 7

MedWrench………………………………………………………IBC

CATEGORICAL ASSOCIATION

INFECTION CONTROL

REPAIR SERVICES

ASCA………………………………………………………………… 25

ALCO Sales & Service Co.……………………………… 25

Cygnus Medical…………………………………………………… 7

CARDIAC PRODUCTS

Cygnus Medical…………………………………………………… 7

Jet Medical Electronics Inc………………………………19

Encompass Group………………………………………………15

REPROCESSING STATIONS

Jet Medical Electronics Inc………………………………19

CARTS/CABINETS ALCO Sales & Service Co.……………………………… 25 Cygnus Medical…………………………………………………… 7 Healthmark Industries Company, Inc.……………41 TBJ Incorporated………………………………………………… 4

CS/SPD MD Technologies Inc.……………………………………… 10 Ruhof Corporation…………………………………………… 2,3

DISINFECTION Cygnus Medical…………………………………………………… 7 Ruhof Corporation…………………………………………… 2,3

DISPOSABLES

Healthmark Industries Company, Inc.……………41 MD Technologies Inc.……………………………………… 10 Ruhof Corporation…………………………………………… 2,3 TBJ Incorporated………………………………………………… 4

INSTRUMENT STORAGE/TRANSPORT Cygnus Medical…………………………………………………… 7 Ruhof Corporation…………………………………………… 2,3

ONLINE RESOURCE MedWrench………………………………………………………IBC OR Today Webinar Series……………………………… 45

OR TABLES/BOOMS/ACCESSORIES Action Products, Inc.……………………………………… 37

MD Technologies Inc.……………………………………… 10 Ruhof Corporation…………………………………………… 2,3 TBJ Incorporated………………………………………………… 4

SAFETY Healthmark Industries Company, Inc.……………41

SINKS Ruhof Corporation…………………………………………… 2,3 TBJ Incorporated………………………………………………… 4

STERILIZATION Cygnus Medical…………………………………………………… 7 Healthmark Industries Company, Inc.……………41 MD Technologies Inc.……………………………………… 10

OTHER

TBJ Incorporated………………………………………………… 4

AIV Inc.…………………………………………………………………13

SURGICAL INSTRUMENT/ACCESSORIES

PATIENT MONITORING

Cygnus Medical…………………………………………………… 7

AIV Inc.…………………………………………………………………13

Healthmark Industries Company, Inc.……………41

Jet Medical Electronics Inc………………………………19

TELEMETRY

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

PATIENT WARMING

AIV Inc.…………………………………………………………………13

FALL PREVENTION

Encompass Group………………………………………………15

TEMPERATURE MANAGEMENT

ALCO Sales & Service Co.……………………………… 25

POSITIONING PRODUCTS

Encompass Group………………………………………………15

Action Products, Inc.……………………………………… 37

WASTE MANAGEMENT

GENERAL

Cygnus Medical…………………………………………………… 7

ALCO Sales & Service Co.……………………………… 25

ENDOSCOPY Cygnus Medical…………………………………………………… 7 Healthmark Industries Company, Inc.……………41 MD Technologies Inc.……………………………………… 10

AIV Inc.…………………………………………………………………13

HOSPITAL BEDS/PARTS ALCO Sales & Service Co.……………………………… 25

Molnlycke Health Care…………………………………… BC

PRESSURE ULCER MANAGEMENT Action Products, Inc.……………………………………… 37

MD Technologies Inc.……………………………………… 10 TBJ Incorporated………………………………………………… 4

WOUND MANAGEMENT Molnlycke…………………………………………………………… BC

Molnlycke Health Care…………………………………… BC

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GET AHEAD OF OCCIPITAL PRESSURE ULCERS IN THE OR. Mölnlycke® Z-FloTM Fluidized Positioners can help protect your patients

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References: 1. Barakat-Johnson M et al. Evaluation of a fluidised positioner to reduce occipital pressure injuries in intensive care patients: A pilot study. Int Wound J. 2018;1–9. 2. Katzengold R, Gefen A. What makes a good head positioner for preventing occipital pressure ulcers. Int Wound J. 2017;1–7.

We’re here to help. Call your Mölnlycke Health Care Representative or Regional Clinical Specialist. 1-800-843-8497 | www.molnlycke.us | 5550 Peachtree Pkwy, Ste 500, Norcross, GA 30092 The Mölnlycke trademarks, names and logo types are registered globally to one or more of the Mölnlycke Health Care Group of Companies. The Z-Flo is a trademark in the United States and other countries of EdiZONE, LLC of Alpine, Utah and USA. Distributed by Mölnlycke Health Care, US, LLC, Norcross, Georgia 30092. © 2019 Mölnlycke Health Care AB. All rights reserved. 1-800-882-4582. MHC-2019-37588

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