OR Today Magazine March 2021

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SURGERY STARTS HERE DISINFECTION METHODS

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PRODUCT FOCUS INFECTION CONTROL/ DISINFECTION

LIFE IN AND OUT OF THE OR

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CE ARTICLE PATIENT HANDLING

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MARCH 2021

PANDEMIC Lessons Learned

from COVID-19

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contents features

38

PANDEMIC PREPAREDNESS: LESSONS LEARNED FROM COVID-19 Perioperative professionals and experts share lessons learned during the COVID-19 pandemic as well as how elective surgeries are resuming and how COVID-19 could change the health care industry going forward.

25

30

48

The infection control market is expected

The goal of this program is to provide

“Influencers” are creative and optimistic

to grow over the next several years to

nurses with information about safe

problem solvers. They are naturally wired

reach $58.2 billion by 2027.

patient handling programs and the

to be team players and use enthusiasm to

rationale for such programs.

motivate others.

MARKET REPORT

CONTINUING EDUCATION

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INDUSTRY INSIGHTS

CIRCULATION

8 News & Notes 14 ASCA: Staying Positive During the Pandemic 16 IAHCSMM: Handling of Explanted Medical Devices Addressed in AORN’s Revised Guideline for Specimen Management 18 Surgery Starts Here: Disinfection Methods – Straightforward or Complicated?

20 AAMI: Steam Sterilization Standard ST79 Receives CommunityDriven Update 22 CCI: Perioperative Nursing – The Apprenticeship Model

25 M arket Analysis: Report: Infection Control Market Worth $58.2 Billion by 2027 26 Product Focus: Infection Control/Disinfection 30 CE Article: Safer Patient Handling Saves Nurses’ Backs

OUT OF THE OR

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OR TODAY | March 2021

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INDUSTRY INSIGHTS

news & notes

STERIS to Acquire Cantel Medical STERIS plc and Cantel Medical Corp. announced that STERIS has signed a definitive agreement to acquire Cantel, through a U.S. subsidiary. Cantel is a global provider of infection prevention products and services primarily to endoscopy and dental customers.

Under the terms of the agreement, STERIS will acquire Cantel in a cash and stock transaction valued at $84.66 per Cantel common share, based on STERIS’s closing share price of $200.46 on January 11, 2021. This represents a total equity value of approximately $3.6 billion and a total enterprise value of approximately $4.6 billion, including Cantel’s net debt and convertible notes. The agreement has been unanimously approved by the boards of directors of

both companies.

“We have long appreciated Cantel, which is a natural complement and extension to STERIS’s product and service offerings, global reach and customers,” said Walt Rosebrough, president and chief executive officer of STERIS. “Our companies share a similar focus on infection prevention across a range of health care customers. Combined, we will offer a broader set of customers a more diversified selection of infection prevention and procedural products and services. We welcome the people of Cantel to the STERIS team and firmly believe we will create greater value for our customers and shareholders together.” •

The Joint Commission Releases Quick Safety on Alleviating Dangers of Surgical Smoke Surgical smoke plume can contain toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde, bioaerosols, dead and live cellular material (including blood fragments) and viruses.

A new Quick Safety advisory from The Joint Commission, “Alleviating the dangers of surgical smoke,” reviews current regulations, recommendations and standards on surgical smoke or lasers from several governmental and professional organizations, including from the Occupational Safety and Health Administration (OSHA), National Institute of Occupational Safety and Health (NIOSH), American National Standards Institute (ANSI), Association of periOperative Registered Nurses (AORN) and ECRI. The advisory also includes several safety actions for health care organizations that conduct surgery and other procedures using lasers and other devices that produce surgical smoke.

Recommended safety actions to protect patients and health care workers include: • Implementing standard procedures for the removal of surgical smoke and plume through the use of engineering controls, such as smoke evacuators and high filtration masks.

• During laser procedures, using standard precautions to prevent exposure to the aerosolized blood, blood by-products and pathogens contained in surgical smoke plumes.

• Establishing and periodically reviewing policies and pro-

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OR TODAY | March 2021

cedures for surgical smoke safety and control – making these policies and procedures available to staff in all areas where surgical smoke is generated.

• Providing surgical team members with initial and ongoing education and competency verification on surgical smoke safety, including the organization’s policies and procedures.

• Conducting periodic training exercises to assess surgical smoke precautions and consistent evacuation for the surgical suite and procedural area.

“While exposure of surgical smoke to patients is shortterm and relatively low risk, surgeons, perioperative nurses and other operating room staff are exposed to surgical smoke daily,” says Ana Pujols McKee, MD, executive vice president, chief medical officer and chief diversity and inclusion officer, The Joint Commission. “At high concentrations, surgical smoke may cause ocular and upper respiratory tract irritation and potentially create visual problems for the surgeon. This is why it is so important for hospitals and ambulatory surgery centers to be aware of the risks of surgical smoke and how they can best mitigate those risks.”

Additional resources from The Joint Commission are provided in the advisory, along with resources from the Centers for Disease Control and Prevention (CDC), ANSI, AORN and several other academic journals. • For more information, visit tinyurl.com/TJCsafety56.

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Clinical Trial to Study Impact of ActivePure Technology on Surgical Site Infections Aerus Medical formally announced the start of a double-blind two-year clinical study to evaluate the impact the Aerus Medical Guardian with ActivePure Technology can have on reducing nosocomial infections, or healthcare-associated infections (HAIs), from surgical operating room procedures.

Aerus Medical Guardian with ActivePure Technology, a U.S. FDA Class II Medical Device, reduces bacteria and viruses in the air by 99.99% within 30 minutes and surface contamination by more than 99% after several hours. The primary goal of the randomized trial will be to determine whether filtering and sterilizing operating room air with the Aerus Medical Guardian with ActivePure

Technology air purifier reduces a composite of serious surgical site infections, infection-related complications, and death within 30 days after surgery. Secondarily, the trial will determine the effect of air filtration and sterilization on serious surgical site infections and on the cost of care.

The Aerus Medical Study will use 50 noncardiac, adult operating rooms at Cleveland Clinic. The trial will be restricted to adults aged 18 years or older, having surgery lasting at least one hour.

Patients with present-on-admission infections will be excluded from the study.

Operating rooms will be randomized in one-month blocks to Aerus air sterilization or conventional air handling. A minimum of 67,653 patients with a maximum of

INDUSTRY INSIGHTS

news & notes

86,639 patients will be needed for this study.

The trial is expected to begin this year and last approximately two years.

The Aerus Medical Guardian with ActivePure Technology is roughly the size and configuration of carry-on luggage and weighs 48 pounds. It cleans 18,000 cubic feet of air per hour on its “high” setting.

The system actively cleans the air with activated carbon, ActivePure Molecules, and high-efficiency particulate filtration.

The Aerus Medical study is sponsored

by Aerus Medical LLC, the company that developed the surface and air purification unit Aerus Medical Guardian with ActivePure Technology. •

CIVCO Medical Solutions, Philips HealthTech Partner on High-Level Disinfection Systems CIVCO Medical Solutions has a new partnership with Philips HealthTech to advance the availability of the ASTRA automated high-level disinfection system for ultrasound probes and other high-level disinfection accessories within the North American market.

Philips now offers ASTRA TEE and ASTRA VR to customers as a reliable and efficient disinfection system to safely reprocess ultrasound transducers.

“We are proud to partner with Philips on the sale of our ASTRA line to their extensive installed base and with new ultrasound system sales,” said Brad Dunlap, vice president of business development at CIVCO. “As a market leader in high-performance TEE transducers, we are excited to support Philips customers’ safe and effective transducer reprocessing with ASTRA TEE, as well as to expand our market coverage for reprocessing transrectal and transvaginal probes with ASTRA VR. We look forward to extending this partnership to offer additional solutions for Philips ultrasound equipment.”

Philips and CIVCO have an extensive history of collaborating on innovative products. CIVCO designs and manufactures custom needle guides for Philips ultrasound systems and trans-

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ducers, including the groundbreaking VerzaLink direct-attach needle guidance system for Philips probe mC7-2. Philips also utilizes the ASTRA disinfection system to reprocess ultrasound transducers at its Bothell, Washington, distribution center.

ASTRA is a validated automated reprocessor for Philips TEE, vaginal, and rectal probes, and its compatibility is outlined in Philips’ “Disinfectants and Cleaning Solutions for Ultrasound Systems and Transducers” user manual. •

March 2021 | OR TODAY

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INDUSTRY INSIGHTS

news & notes

Encompass Group Shares Airisana News Encompass Group LLC premiered its Airisana Therapeutic Support Surface in June 2019 at the WOCNEXT 2019 Conference in Nashville, Tennessee.

Over the last 18 months, Airisana has been well received by the nursing community because it has provided a cost-effective solution that drives savings, supports a reduction in pressure injury (PI) prevalence and risks, drives reductions in patient and staff injury and is simple to clean and store. Each unit comes with an intuitive soft touch user control panel that’s quiet enough to keep the healing environment comfortable, and still keeps control in the care provider’s hands.

Pressure injuries are generally not the primary reason a patient is admitted to a hospital, but they place a burden on patients and caregivers alike and can increase operational costs. “While many hospital-acquired conditions (HACs) have decreased, pressure injuries remain a stubborn exception.

Contributing factors such as increased acuities, decompensation, increased use of medical devices and patient adaptation all play a role,” said Michelle Daniels, Airisana managing director for product development. “Airisana helps turn this tide around, providing ongoing support for both the patient and patient care team. It’s one more tool in their caregiving arsenal. Airisana has returned savings of more than 120% when purchased, compared to the cost of traditional, rented therapeutic support

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OR TODAY | March 2021

surfaces. This translates to a return on investment within 2-3 months. Combined with the benefits of its revolutionary design, and easy implementation, it helps nurses, clinicians and their institutions battle pressure injuries.”

Repeating pressure therapy patterns in traditional therapeutic support surfaces increases the probability that a patient’s body can adjust to the surface, negatively impacting healing.

Airisana reduces this risk with randomized pressure therapy modes that promote sustained pressure reduction and combine the benefits of multiple pressure therapies into a constantly changing surface the body doesn’t get used to. These include: Alternating pressure, pressure redistribution, low air loss, and lateral rotation, immersion/envelopment. Airisana conforms evenly to irregularities such as a patient’s body contours. This puts the greatest amount of contact between skin and surface and ensures decreased pressure without interfering with patient mobility. And Airisana is even emergency-ready – with a CPR deflate function and a quick access hose that allows intervention when needed most. With turn assist reducing friction and shear risk, and preventing caregiver injury, nurses and clinicians can now easily reposition patients as needed. • For more information, visit encompassgroup.com.

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INDUSTRY INSIGHTS

news & notes

Ambu Awarded GPO Contract Ambu Inc. has been granted a national single-use endoscopy contract in the category of single-use endoscopes with a major U.S. group purchasing organization (GPO).

This contract gives Ambu a sole position in both singleuse bronchoscopes and single-use rhinolaryngoscopes for the duration of the contract.

The single-use endoscopy category is new for the GPO and will be effective through November 2023. It enables Ambu to more effectively serve 160 acute care hospitals in the United States and over 2,600 total sites in more than 20 states. This agreement can further accelerate Ambu’s share of the single-use endoscope market

by giving those accounts pre-negotiated pricing and terms for Ambu’s bronchoscopy and rhinolaryngoscopy products.

“We’re seeing a trend that GPOs now create dedicated single-use endoscopy categories which means that hospitals and health care providers get easier access to advanced single-use devices. With our portfolio in innovative single-use endoscopy, we are the ideal partner to help medical professionals prevent device-related infections and improve health care economics,” said Juan Jose Gonzalez, CEO of Ambu A/S. •

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March 2021 | OR TODAY

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INDUSTRY INSIGHTS

news & notes

Karl Storz Announces New Imaging Technology Karl Storz Endoscopy-America Inc. has announced its latest advancement in endoscopic imaging. The Image1 S Rubina multimode visualization system combines state-of-the-art 4K resolution with enhanced fluorescence-guided imaging using near-infrared light and indocyanine green dye (NIR/ICG). The system uses unique and proprietary dual-4K sensors and dual-LED light technology to toggle seamlessly between white-light and fluorescence modes, without the lag or

mismatched frames that are common with alternative technologies. The Image1 S is a modular system, existing 4K customers can upgrade to this technology for half the cost of competing technologies (based on upgrading an existing Image1 S system).

Image1 S Rubina allows physicians to switch among several viewing modes to suit different surgical needs including 4K Overlay, Monochromatic and Intensity Map maodes.

In addition, the new and improved

Rubina telescopes now offer one scope for every procedure, be it white light or NIR/ICG. The new design uses a proprietary glass technology that delivers edge-to-edge clarity and eliminates the need for refocusing when switching between white light and NIR modes. Exceptional image quality, improved workflow and standardization lead to clinical, operational and financial advantages. •

PENTAX Medical Releases endoPRO 20|20 PENTAX Medical recently launched its endoPRO 20|20 software, a distinctive endoscopy image management and patient data analysis system that provides efficiencyfocused workflow enhancements and ensures pathology results are available in a streamlined and timely manner.

A next generation system, the endoPRO 20|20 pathology engine offers functionality that leverages HL7 Interfacing and PENTAX Connect to create interoperability between disparate hospital systems, delivering efficient procedure reporting and quality indicators.

With diminishing reimbursement and growing pressure on physicians to increase volume, capturing and reporting appropriate quality indicators to increase operational efficiency and to facilitate clinical improvement has become imperative for facilities and practitioners. The new endoPRO 20|20 software has been specifically developed to fulfill these needs, with a focus on providing a seamless pathology workflow, integration, and automation.

EndoPRO 20|20 offers a comprehensive system to support efficiency at each stage of the workflow, from requisition to results to patient follow-up, also providing specific options to best suit facility needs and processes. Among the new features, it aids physicians in the calculation of Adenoma Detection Rates (ADR), transforming a resource-

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OR TODAY | March 2021

intensive process into one that is automated and efficient, so endoscopists no longer need to calculate their ADR manually. Additionally, endoPRO 20|20 eliminates the need for pathology results to be siloed in the Electronic Medical Record (EMR) or paper patient records, allowing the physician to review the pathology while they are completing procedure reports.

Further key highlights of the endoPRO 20|20 pathology engine include the ability to generate notifications for physicians when new results are available. The engine will also analyze a patient’s pathology results based on specific categories and recommend appropriate follow-up examination dates based on those results and endoscopy society guidelines.

With endoPRO 20|20, there is also the addition of DICOM support, which facilitates the easy transmission of procedure images to the hospital PACS system for retrieval or printing, as well as compatibility with the recently introduced PENTAX Connect for Capsule Endoscopy that interfaces the CapsoCam Plus software with the hospital EMR software. •

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INDUSTRY INSIGHTS

news & notes

JUNE Medical Partners with Vivo Surgical JUNE Medical has announced the launch of the Galaxy II LUX – the worlds’ first self-retaining ring retractor with light. The Galaxy II LUX combines the award-winning Galaxy II retractor with Vivo Surgical’s KLARO in vivo LED device, which can be mounted on the retractor via a purpose-designed clip. This unique partnership provides surgeons with a revolutionary solution, giving them better access and a clearer view of the surgical site, and eliminating

the disadvantages of using overhead lighting or personal headtorches.

The lightweight, self-retaining Galaxy II retractor features unique cam locks that allow single-handed adjustment on the frame, and there are multiple frames and hooks to suit a range of procedures. The KLARO lighting tip then offers the highest surgical light intensity on the market, with four settings to match the needs of different operations, while maintaining a safe operating

temperature of below 38°C. With a 650 mm long cable, compact 4.6 mm diameter and flexible structure, the light can be effortlessly positioned during surgery to offer up to ~340° of illumination inside deep and narrow wounds.

The Galaxy II LUX is ideal for use in a variety of procedures, including ENT, colorectal, orthopaedic, gynaecological and other open surgeries. •

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March 2021 | OR TODAY

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INDUSTRY INSIGHTS ASCA

Staying Positive During the Pandemic

By Bill Prentice ith confirmed cases

W of COVID-19 at an alltime high and several states and hospital systems again suspending elective surgeries, the first quarter of 2021 is setting the stage for another challenging and unpredictable year. It can help to remember that we have already received some good news for 2021 and could see more before year-end.

ASCs Deliver Safe Surgery Despite Pandemic The good news for patients in need of outpatient surgery is that, across the country, health care providers and policymakers have recognized that elective surgery is not the same thing as optional surgery and are allowing ASCs to remain open to provide this care. Patients who elected to postpone the surgery they needed after the coronavirus was discovered in the U.S. about a year ago are finding that ASCs can safely provide their care, even during the pandemic, and taking advantage of the opportunities ASCs offer.

The good news inside ASCs is that the new patient safety precautions that facilities have adopted since the pandemic was declared, 14

OR TODAY | March 2021

including masking and social distancing, are leading to high-quality outcomes and extremely rare reports of patients contracting COVID-19 following a procedure in an ASC. Two surveys – one conducted by the ASC Quality Collaboration and involving 700 facilities and the other conducted by ASCA and involving 631 facilities – confirm that finding.

The presence of the coronavirus in the U.S. has also led many ASCs to review their infection prevention policies and procedures as well as intensify their focus on making sure they are doing all they can to protect their patients and staff from infections of any kind. In fact, last July, I talked about the risks involved in delaying certain elective surgeries with board-certified gastroenterologist and former ASCA board member Tom Deas, MD. Deas suggested that by that time, thanks to new protocols that were developed and adopted nationally to prevent the spread of the virus, ASC endoscopy units had probably become some of the safest places on earth when it came to avoiding COVID-19. ASCs might be far safer, he suggested, than a post office, barber shop or restaurant. He also said he

would be perfectly comfortable having an endoscopic procedure in an ASC that had implemented the new protocols. Anyone interested in that conversation can go to the July 15, 2020, episode of ASCA’s Advancing Surgical Care Podcast, “The Risk of Delaying Certain Elective Surgeries,” to hear more. It can be found online at tinyurl.com/RiskOfDelay2020.

Vaccine Distribution Continues One of the biggest developments in the country’s battle against the coronavirus this year, of course, is the rollout of the vaccine that began late last year. Health care and frontline emergency workers were receiving some of the earliest available vaccines and, in most states, ASC staff were high on the list of those next in line. If the vaccines work as expected, people across the country could begin to see significant changes in the restrictions they have been under in the last year.

Medicare’s New Payment Rule Allows More Procedures at ASCs Medicare’s 2021 final payment rule also contained some good news for ASCs and their patients. For one, the rule adds 267 procedures, WWW.ORTODAY.COM

INDUSTRY INSIGHTS ASCA

including total hip arthroplasty, to the ASC Covered Procedures List (ASC CPL) beginning this year.

That means that more Medicare beneficiaries can have more of the outpatient surgery they need in an ASC. ASCs that have been performing total hip arthroplasty and seeing excellent outcomes in their privately insured patients for some time are particularly pleased to see that procedure now available to Medicare beneficiaries in ASCs. In other good news this year, thanks to the continued use of the hospital market basket to set both ASC and hospital outpatient department (HOPD) payment rates, ASCs and HOPDs got the same 2.4% inflation update. The use of the hospital market basket in determining the annual updates for both entities is something the ASC community has been requesting for some time, and although we are still in a trial period, we are pleased to see that CMS is continuing with its plan to evaluate the use of that measure to set the updated rates for both ASCs and HOPDs. While other parts of the Medicare payment system still need to be addressed, this one change could help slow the steadily increasing disparity between ASC and HOPD rates that we have seen since the current ASC payment system was introduced in 2008.

End-of-Year Legislation Offers Policy Updates and Financial Relief Other positive news for ASCs and their patients in 2021 came in endof-year legislation that was signed

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into law late in December. After years of requests from ASCA and many others, that new law, known as the Consolidated Appropriations Act, 2021, creates a fix to the patient copay penalty invoked whenever a screening colonoscopy transforms into a diagnostic colonoscopy with the removal of a polyp. The Medicare beneficiary copay now in place will be phased out between January 2022 and January 2030.

This legislation also authorized additional financial assistance to businesses that have experienced financial losses during the pandemic and makes clear that, for tax purposes, gross income will not include any amount that would arise from the forgiveness of a Paycheck Protection Program loan. As a way of offsetting some of the financial uncertainty ASCs and other health care providers have experienced since the temporary halt of elective surgeries early last year, the legislation also continues to suspend sequestration through March 31, 2021. That suspension means that providers are fully reimbursed for the services they provide to Medicare patients until sequestration payment reductions are reactivated.

ASCA and its members had advocated for all of those actions.

Support for ASCs on Capitol Hill While it is too soon to say for sure exactly what the ASC community can expect from the new administration, we do know that many ASC champions are returning to the U.S. Congress and are poised to assume

key positions on committees with jurisdiction over our issues. ASCs, however, have always enjoyed support from both sides of the aisle.

ASCA and its members continue to cultivate bipartisan support for the ASC community by educating all members of Congress about the many benefits ASCs provide. After retooling our ASC tour program last year, in response to the coronavirus quarantines, we now have a virtual tour toolkit to support these efforts.

Anyone interested in learning more about these efforts should contact ASCA’s Director of Government Affairs and Regulatory Counsel Kara Newbury at knewbury@ascassociation.org.

ASC Advocacy Continues We are pleased to see several of the policies that ASCA and its members have long supported being adopted this year. We are also grateful that the ASC community was consulted and considered as a national response to the coronavirus pandemic was coordinated. Still, we have a great deal of work ahead of us in 2021 and beyond and recognize that ASCs are most effective when they speak with a united voice. ASCA continues to stand ready to be that voice, to convene the conversations needed to address new challenges and to continue to work to achieve the legislative and regulatory policies needed to serve the ASC community and the patients who need the care that ASCs provide.

March 2021 | OR TODAY

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INDUSTRY INSIGHTS

IAHCSMM

Handling of Explanted Medical Devices Addressed in AORN’s Revised Guideline for Specimen Management

By Susan Klacik, BS, CRCST, CIS, CHL, ACE, FCS n Dec. 14, 2020, the Association of periOperative Registered Nurses’ (AORN’s) Guideline for Specimen Management was released to electronic subscribers and will be published in the 2021 print book edition. Recommendation 13 of this document provides pertinent information for sterile processing (SP) professionals in regard to handling of explanted medical devices (implanted medical devices that have been surgically removed).

O

SP professionals must manage explants safely and properly any time a request is made to sterilize an explanted device, such a s screw, hip, plate and so on, for return to the patient. Numerous factors must be considered when handling explanted devices, and this updated guideline’s new recommendations can assist with those issues. Note: While the previous version of the guideline addressed the handling of explanted medical devices, the updated version includes new recommendations.

Key points covered in recommendation 13 Recommendation 13 of the new guideline begins by mentioning that explanted medical devices are regulated medical devices that require health care facilities to handle them safely and consistently – in accordance with federal, state and local regulations, and the device manufacturer’s instructions for use (IFU). Health 16

OR TODAY | March 2021

care facilities should have policies and procedures in place pertaining to the handling of explants; this updated guideline features information to consider when such policies and procedures are developed.

Whenever an implant procedure is performed, the health care becomes the final distributor of the implanted device and is required to track the implant to the patient, per regulations set forth by the U.S. Food and Drug Administration (FDA). As the final distributor, health care facilities must meet medical device tracking requirements and provide information to the manufacturer about explanted devices. Medical device tracking benefits facilities and patients if notifications and recalls are needed. Explanted medical device tracking may also provide critical information about device use, life expectancy of the device and the device’s failure, all pertinent information that can help improve devices and aid clinical decision-making surrounding a device’s use.

When a health care facility reports explants to the manufacturer, the following information must be provided in the report: • Date the device was explanted; • Name, mailing address and telephone number of the explanting physician; and • Date of the patient’s death or the date the device was returned to the manufacturer, permanently retired from use or otherwise disposed of permanently; and

•

A product code that specifies the type of implant. Note: The revised guideline features a table with the product code for medical devices requiring manufacturer tracking.

If the manufacturer cannot be located, the report must include the process used to contact them.

Deaths related to an implanted medical device must also be reported, per FDA regulation, and serious injury related to an implanted medical device must be reported to the device manufacturer. If the medical device manufacturer cannot be identified, the injury must be reported to the FDA (implant malfunctions can be reported by the health care organization using the FDA voluntary MedWatch program).

If an implant must be returned to the manufacturer, it is recommended that they be returned in accordance with the manufacturer’s instructions and the facility’s policies and procedures. This process helps protect the device from damage during shipping and reduces the risk of leakage of potentially hazardous or infectious materials during transport.

Note: The unique device identifier (UDI) from explanted medical devices should be documented in the patient’s medical record or recorded in a facility tracking log, when available.

To avoid confusion or regulatory noncompliance, the guideline recommends health care organizations develop specific policies and procedures for handling explanted medical devices. These policies and procedures should be developed by WWW.ORTODAY.COM

INDUSTRY INSIGHTS

IAHCSMM an interdisciplinary team that includes perioperative leaders, legal advisors, risk management personnel, pathologists, surgeons, anesthesia professionals, infection preventionists, SP professionals and materials management personnel.

According to the guideline, policies and procedures pertaining to explanted medical devices should address the following: • Medical device tracking; • Reporting of patient death or serious injuries; • Returning devices to manufacturers; • Submission to the pathology laboratory (if required); • Documentation of explants; • Disposal of devices; and • Which devices may be returned to the patient (this should address procedures for communi-

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cating with personnel who perform explanted device processing; decontamination processes that will be used in the facility; and liability release of the facility that processes the explanted device, if explanted devices are returned to the patient).

Note: The guideline has a no recommendation rating for returning explanted medical devices to patients. Because AORN guidelines are evidence-based, there is no evidence of a clear benefit of returning the explants to the patient. The balance between the benefits and potential risks of returning explanted medical devices to the patient or patient’s family is unclear, and many factors must be considered.

Conclusion The newly revised Guideline for Specimen Management provides SP profession-

als with information on how to handle explants, including how to manage the process whenever a request is made to return an explant to a patient. Numerous factors must be considered and the decision of decontaminating and sterilizing an explant for return to a patient should be included in an explant policy. An explant handling policy should be readily available to appropriate personnel, so when a request is made to deliver an explant to a patient, SP professionals and other stakeholders can ensure they are able to meet that request safely, consistently and in compliance with regulations and the facility’s policies and procedures.

Susan Klacik, BS, CRCST, CIS, CHL, ACE, FCS, serves as a clinical educator for the International Association of Healthcare Central Service Materiel Management (IAHCSMM).

March 2021 | OR TODAY

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INDUSTRY INDUSTRY INSIGHTS INSIGHTS Surgery

news notes Starts & Here

Disinfection Methods – Straightforward or Complicated?

By Brandon Huffman, BS, CRCST, CIS ith all the different cleaning, disinfecting and sterilizing processes that go on inside of hospitals, I find disinfection to be the most complex and complicated among them. Disinfection is often looked upon as a simple concept needing no advanced experience or education. You can generally find disinfection processes outside of sterile processing departments in radiology, respiratory therapy, physical therapy, endoscopy, dental offices, you name it. But the question remains, should disinfection be performed outside of sterile processing?

W

Before we explore this question, I believe we need to break down the complexity of disinfection and how we apply it first. If you look up the definition of disinfection, you may find it to be misleading and somewhat lost in translation. This is due to disinfection having different forms and different activity levels of strength depending on the purpose of its uses. Having a single definition isn’t practical since disinfection can represent different expected outcomes. The Spaulding Classification is a great place to start when determining the appropriate 18

OR TODAY | March 2021

method and activity level of a disinfectant to be used. Under the Spaulding classification, disinfection is applicable to the semi-critical and non-critical categories with the critical category belonging to sterilization. The Spaulding categories are of course not to be confused with disinfectant activity levels which are low-level, intermediate-level and high-level.

Let’s jump into the methods of disinfection. Disinfection is most often known in the chemical form as you may have observed during this current COVID-19 pandemic. Hospitals and people in general were desperately trying to purchase disinfecting wipes and chemicals with active ingredients such as isopropyl alcohol in order to keep surfaces disinfected and safe. The chemical forms of disinfection are also well known if you disinfect items such as flexible endoscopes, for instance; Ortho-Phthalaldehyde (OPA) and Peracetic Acid are two well known high-level disinfectants used for that purpose.

One other popular type of disinfection is thermal. Thermal remains one of the top disinfection processes for surgical instrumentation in sterile processing departments. Thermal disinfection is generally fully automated and built into instrument washers that are already performing the function

of automated cleaning. Ask any sterile processing technician who has picked up a tray from the automated washer too soon and they will let you know just how hot thermal disinfection can get.

Now that we have covered a couple of popular methods of disinfection, we should discuss the activity levels.

Different methods of disinfection can be utilized across different levels of disinfection activity depending on the type, temperature and time frame of application. I know it sounds confusing but stick with me. Thermal disinfection, for instance, can achieve all three activity levels of disinfection depending on the temperature and time of application. Thermal disinfection is used to achieve intermediatelevel disinfection for safe handling of surgical instrumentation during the assembly process. It is also used to achieve high-level disinfection for items such as respiratory equipment in between patient uses. The only difference may be the amount of time the items are exposed to a certain water temperature.

Chemical disinfection can have the same capabilities of reaching across multiple disinfection activity levels as well, however, you need to make sure you read the instructions for each chemical used to verify its capabilities WWW.ORTODAY.COM

and surfaces or items it is validated to disinfect. Generally, chemical disinfectants are designed to achieve specific disinfection activity levels for specific purposes.

That was a lot to cover, and I’m glad you stuck it out. We should now circle back to the question of whether disinfection should be performed outside the sterile processing department. I believe when it comes to the activity levels of low- and intermediate-level disinfectants, those most certainly can and should occur outside of sterile processing. These, of course, cover the general cleaning and disinfection of the environment and equipment that only encounters intact skin. I do, however, believe that high-level disinfection should remain a sterile processing function to be performed by competency validated technicians. This is not only due to the level of training and knowledge required to perform the function of high-level disinfection, but also because sterile processing is usually designed to handle the potentially dangerous chemical disinfection process with areas supported by negative air pressure and proper personal protective equipment (PPE). Chemical disinfection can be hazardous if proper ventilation and proper PPE use are not in place.

All in all, disinfection remains a highly complex and challenging process that is further complicated by the workflows and products each facility utilizes and/or has access to.

With some process observations and a full risk assessment you can determine whether your high-level disinfection processes are adequate, or a patient/employee safety issue waiting to happen.

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

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INDUSTRY INSIGHTS AAMI

Steam Sterilization Standard ST79 Receives Community-Driven Update fter three years, a widely used standard in health care and industry has undergone an important update. The Association for Advancement of Medical Instrumentation (AAMI) has released four amendments to ANSI/AAMI ST79 “Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities,” offering users new clarity and fresh guidance to stay in compliance with accrediting bodies.

A

“All standards are living, evolving documents,” said Sarah Friedberg, a microbiology manager at Stryker Endoscopy and co-chair of the AAMI working group that authored the amendments. “As technology advances, scientific knowledge improves, and industry practices change, there’s often a need to revisit our standards.”

ANSI/AAMI ST79 is a particularly important standard because it provides comprehensive guidance to health care personnel who use steam for sterilization, regardless of the size of the sterilizer or the type of facility. This includes hospitals, ambulatory surgery facilities, physician offices, cardiac catheterization laboratories, endoscopy suites, radiology departments and dental offices. It remains a go-to document for The Joint Commission.

In 2017, the standard was revised from its 2010 version to provide flex-

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OR TODAY | March 2021

ible guidance for this wide variety of users while also providing new strategies for assuring the safety of sterilization professionals.

The AAMI Standards working group responsible for the 2017 update anticipated questions and comments to follow these initial changes. Since then, the AAMI working group STWG 40 has heard from manufacturers, health care facilities and even biologists. The group typically meets twice a year in conjunction with AAMI Sterilization Standards meetings and, according to the group’s co-chairs, participants are not shy about sharing their thoughts and questions.

“Writing a standard is really a balancing act because it’s covering such a broad swath of venues, and yet everyone also needs the right specifications,” said Susan Klacik, ST-WG 40 co-chair and clinical educator at International Association of Healthcare Central Service Materiel Management (IAHCSMM). “Through AAMI, we have this wonderful collaborative community.

We can collect everybody’s views in one place and really iron out what is working versus what isn’t.”

After three years of collecting feedback, the working group’s efforts have culminated in ANSI/AAMI ST79:2017’s 2020 amendments.

Recommendations and clarifications were added for maintaining the integrity of the sterile processing area. This includes even “common sense” additions, such as stipulating that there should be no food or drink in the area.

Other amendments were made to best practices, such as how often sterilizers in health care facilities should be cleaned. The group also built upon recommendations for the instrument inspection process, recognizing that relatively new technologies, such as borescopes and Adenosine Triphosphate (ATP) monitoring, enable more thorough inspections and record keeping.

“These amendments weren’t made in the interest of one company or one hospital. We set our day jobs aside and that’s what made it work so well,” added Friedberg. “Even manufacturers and hospitals, despite obvious differences, want the same thing. An instrument should work perfectly each-andevery time … That kind of reliability ensures user and patient safety.”

How to Get the Amendments The amended document is available through AAMI at aami.org/ST79.

ANSI/AAMI ST79:2017. It will be automatically updated for users with an AAMI eSubscription. For those who previously purchased the printed version or own a PDF of the current edition, a PDF of the amendments will be emailed to them at no cost.

For those who do not yet have the current edition of the standard, ST79:2017, it is available for purchase from the AAMI Store with the amendments included.

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INDUSTRY INSIGHTS CCI

Perioperative Nursing – The Apprenticeship Model

By James X. Stobinski, Ph.D., RN, CNOR, CSSM (E) or the last 3 months I have written about the challenges of perioperative nursing in recruiting nurses into our profession. Even with the disruption of the pandemic, surgery continues and the need for skilled perioperative nurses remains.

It is possible that some of our most experienced clinicians have left perioperative nursing during the pandemic and when surgical volume does return our staffing shortfalls may be exacerbated. However, as I described last month, we are still faced with some fundamental issues that include the lack of a nationally recognized credential for entry into our profession.

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The current standard for entry into perioperative nursing resides mainly in the documentation that the employer must provide for accreditation requirements. Ultimately, the leadership of the facility must document that the nurse possesses competency to practice in their perioperative role. There is no prescribed educational course or a standardized curriculum required by accreditation standards. There is no standardized assessment of knowledge or competency akin to the NCLEX for entry into perioperative nursing. Secondary to variability in roles and work settings accreditation bodies use general language regarding knowledge, skills, abilities and 22

OR TODAY | March 2021

personal attributes when speaking to nursing competency and defer to the employer for specific information.

The research-based evidence on our current orientation methods is not extensive. Tilley (2008) delineates an issue regarding competency assessment in nursing when she states, “Currently, in most states, a nurse is determined to be competent when initially licensed. Continued competency is assumed thereafter unless otherwise demonstrated.”

In a very practical sense, a registered nurse with a valid license is assumed to possess competency in the highly specialized field of perioperative if the employer documents that competency.

All of these are big issues, but as Lee Iacocca once said, “We are continually faced by great opportunities brilliantly disguised as insoluble problems.” The Competency and Credentialing Institute (CCI) believes there also opportunities analogous to what Iacocca described.

At CCI, we propose to address the need for a credential upon entry to the profession and to document the knowledge, skills and abilities of perioperative nurses early in their career. In mid-2021 we will operationalize a credential which will precede the CNOR and CNAMB certifications. This new credential will be designed to meet the professional development needs of nurses early in their careers. We propose a bridge credential that spans the

period from the end of a nurse’s orientation to perioperative nursing and the two-year mark when they become eligible for other CCI certifications.

We intend a rigorous path of assessment and self-reflection which will be consistently documented and provide a digital resume of the education and training for perioperative nurses. The certification will be documented with digital badges which will allow a previously unattainable level of documentation and portability. Innovations such as these are possible with the resources of our new testing partner, PSI Services, a world leader in testing and assessment with over 70 years of experience in the field.

Our aspiration as a non-profit supporting the career development of perioperative nurses is that this new credential will provide a widely accepted, nationally recognized benchmark for perioperative nursing education and training. This will be a new and innovative approach and it does entail some risk. As Niccolò Machiavelli said, “ … there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.” At CCI, we believe it is an approach worth exploring. Stay tuned. There are some exciting new things coming to perioperative nursing certification in the coming year.

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References Good Reads (2020). Niccolò Machiavelli > Quotes > Quotable Quote.

Accessed November 27, 2020 at: https://www.goodreads.com/ quotes/274551-it-ought-to-be-remembered-that-there-is-nothingmore.

Inspirational Stories (2020). Lee Iacocca Quotes. Accessed November 27, 2020 at: https://www.inspirationalstories.com/quotes/lee-iacoccawe-are-continually-faced-by-great-opportunities/.

PSI Services LLC. (2020). Where people meet potential. Accessed November 27, 2020 at: https://www.psionline.com.

Tilley S. (2008). Competency in nursing: A concept analysis. J Contin

Infusion Pump Support & Power Solutions

Educ Nurs. 39(2): 58-64.

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

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March 2021 | OR TODAY

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IN THE OR

market analysis

IN THE OR

product focus

Report: Infection Control Market Worth $58.2 Billion by 2027

Staff report ccording to a market research report from Meticulous Research, the infection control market is expected to grow at a compound annual growth rate (CAGR) of 13.3% to reach $58.2 billion by 2027.

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Infection control is an essential measure across the health care industry to avoid infectious diseases. Factors such as the rising incidences of hospital-acquired infections, growing number of surgical procedures, increasing incidence of chronic diseases associated with the geriatric population and the growing medical device reprocessing industry are significantly impacting the growth of this market.

Infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites or fungi. These diseases can spread, directly or indirectly, either from one person to another, from infected or non-sterilized surgical or medical devices used to treat a person, or from being in the infected environment of any health care facility. Thus, to prevent and reduce the occurrence rate of infectious diseases, health care facilities adopt infection control methods and programs to improve the quality of care and provide a safe environment to the patients and other personnel working in the same facilities.

In recent years, it was observed that the rate of HAIs is on a continuous rise and includes common infections, such as bloodstream infections (BSIs), pneumonia, urinary tract infections (UTIs) and surgical site infections (SSIs). These infections can threaten a patient’s health and life and prolong hospital stays, thereby creating an additional economic burden. These infections contribute to about 10% of the total reported infections in developed and developing countries.

According to ECD Systems LLC WWW.ORTODAY.COM

data, the five most common types of HAIs, include surgical site infections (SSI), ventilator-associated pneumonia (VAP), central-line associated bloodstream infections (CABI), clostridium difficile infections (CDI) and catheter-associated urinary tract infections (CAUTI), cost around $ 9.8 billion annually in the U.S., with SSIs contributing the largest share of 33.7% ($3.3 billion). The high cost of SSIs is mainly because of prolonged hospitalization of patients and associated diagnostic tests and treatment. This leads to an increase in additional cost burden, and hence to reduce this burden, it is necessary to control infections that occur during surgical procedures. This is expected to drive the market for SSI control products in the coming years.

COVID-19 has had an impact on the infection control market.

With the severe outbreak of COVID-19, there is an unprecedented global demand for advanced health care facilities, services and infrastructure to treat the infected. Infection control products, such as personal protective equipment, has seen an unprecedented increase in demand from most countries worldwide to handle a surge of COVID-19 patients. Health care workers rely on personal protective equipment to protect themselves and their patients from being infected and infecting others. Due to growing cases of COVID-19, the available face masks and gowns capacity is insufficient, and the global health care industry is experiencing a shortfall. The WHO estimates that 89 million medical masks will be required every month. To meet that demand, a 40% increase in manufacturing is expected. The WHO also estimates that frontline workers would need approximately 7-10% of the world’s supply of surgical masks, and possibly more. For examination gloves, that figure goes up to 76 million, while international demand for goggles stands at

1.6 million per month.

From a demand perspective, nearly 70-80% of hospitals struggle with a shortage of ventilators, masks, other personal protective equipment, hospital beds, and other supplies. With disturbed supply chains and production capacity shortages, manufacturers of hospital beds and supplies cannot meet the demand. As a result, various countries with high infection rates face huge shortfalls for infection control products. The majorly impacted countries are present in the developed region, and thus to address this situation, government agencies in every country are focusing on alternative ways to increase the production capacity.

The infection control market study by Meticulous Research also evaluates industry competitors and analyzes the market at regional and country levels.

Geographically, North America is estimated to dominate the global infection control market in 2020, followed by Europe and Asia-Pacific. This growth in North America can be attributed to the increasing hospital and outpatient visits, rising number of surgical procedures, growing number of HAIs, increasing health care expenditure, growing pharma and biotech industry, increasing aging population with chronic diseases, and government initiatives to reduce HAIs and implement effective infection control practices.

However, Asia-Pacific is expected to grow at the fastest CAGR during the forecast period. The factors driving the growth of the APAC market include the economic growth of many countries, growing government focus on the health care sector, rising prevalence of infectious diseases, including COVID-19 and government initiatives for boosting infection control procedures.

March 2021 | OR TODAY

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IN THE OR

product focus

CenTrak

Differential Air Pressure Sensor CenTrak’s Differential Air Pressure Sensor offers a reliable and cost-effective solution to meet regulatory requirements and protect patients from environmental contagions.

Leveraging wireless networks, the sensor is easily installed to monitor airflow. If air pressure differentials are outside of the preconfigured range, customizable alerts can be transmitted via email and SMS, in addition to local audible tones and LED lights. Automatic data collection and report generation eliminates human error and the cost of manual documentation.

In addition to operating rooms, CenTrak DAP sensors are used in isolation rooms, sterile processing departments and hospital pharmacies. •

CINTAS

Disinfecting Wipes and Sanitizing Wipes Cintas now offers disposable Disinfecting Wipes and Sanitizing Wipes. When used according to the manufacturer’s instructions, the Disinfecting Wipes clean and disinfect in one step, killing 99.9% of germs on washable hard, non-porous surfaces such as doorknobs and tables. The disposable Sanitizing Wipes are made with a fastacting, alcohol-free formula intended for topical use. Disinfecting Wipes and Sanitizing Wipes are available in portable buckets or floor stands.

The portable buckets are durable and easy to move and the floor stand’s accessible, sleek design fits well in front-of-house areas. •

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OR TODAY | March 2021

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IN THE OR

product focus

HALYARD and BELINTRA SMART-FOLD Sterisystem

The HALYARD and Belintra SMART-FOLD Sterisystem combines HALYARD SMARTFOLD Sterilization Wrap with the Belintra storage and transport system creating a unique system that allows for more secure and sterile surgical tool handling, transport and storage until use in the OR. Through the system’s stainless-steel instrument trays and transport shelves, it helps increase efficiency and organization in the OR by effectively utilizing storage space, reducing touchpoints and minimizing inspection time. During a time when limiting infection exposure and maintaining sterilization is more important than ever, the HALYARD and Belintra SMART-FOLD Sterisystem works as a partner in the OR to keep surgical tools organized, sterile and efficiently accessed. •

CIVCO

ASTRA Automated Reprocessors ASTRA Automated Reprocessors for transesophageal (TEE) and endovaginal/endorectal ultrasound probes offer enhanced capabilities to help facilities stay compliant with The Joint Commission standards. Tracking all necessary disinfectant solution and test strip information, ASTRA fully eliminates the need to log data manually. ASTRA disinfects up to two probes at a time, without sleep cycles, for faster probe turnaround and increased efficiency.

Significant savings are possible with ASTRA’s use of reusable, industry-leading disinfectants: RevitalOx RESERT (hydrogen peroxide), CIDEX OPA and MetriCide OPA. Flexible payment options can help facilities reduce operating costs compared to other leading automated reprocessors. •

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March 2021 | OR TODAY

27

IN THE OR

product focus

Healthmark Industries

TOSI Washer Test Reveal the hidden areas of instruments with the TOSI washer test, the easy to use blood soil device that directly correlates to the cleaning challenge of surgical instruments. TOSI is the first device to provide a consistent, repeatable and reliable method for evaluating the cleaning effectiveness of the automated instrument washer. This is possible because the blood soil is manufactured to exacting specifications each and every time. When metered on to the stainless-steel plate, the TOSI is completely analogous to a stainless-steel instrument soiled with dried blood. Placed in the see-through plastic holder, the challenge is identical to the areas of instruments typically hidden from view (i.e., box locks).

The routine use of this test will help ensure that your instrument washer is performing at a consistent level, enhancing the routine visual inspection of instruments. TOSI complies with new AAMI and AORN Guidelines as well as ASTM Guide D7225. •

TBJ Inc.

PPE Storage Equipment TBJ manufactures a variety of personal protection equipment storage solutions for hospitals, labs and research facilities for the organized storage of disposable protective coveralls, gloves, goggles, facemasks, foot covers and hair covers. TBJ offers a range of storage equipment options including compartmentalized floor-standing and wall-mounted stainless steel cabinets, wall-mounted stainless-steel gowning bins and modular pull-out polycarbonate bins with stainless-steel slides and support shelves. • For more information, visit www.tbjinc.com.

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OR TODAY | March 2021

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IN THE OR

product focus

RUHOF

Biocide Detergent Disinfectant Pump Spray Ruhof’s Biocide Detergent Disinfectant Pump Spray is a ready-to-use quaternary germicide cleaner and disinfectant for use on all hard, non-porous inanimate environmental surfaces in patient rooms, operating rooms, ICU areas, public restrooms or any other area that needs to be disinfected. It is formulated to be highly effective against a broad-spectrum of pathogenic microorganisms, including bacteria, antibiotic resistant bacteria, viruses, fungi, mold and mildew. The product has been tested and was found to kill SARS-CoV-2, the virus that causes COVID-19, in just one minute. In addition to cleaning and disinfecting, Ruhof’s Biocide Detergent Disinfectant Pump Spray deodorizes smelly areas such as garbage storage areas, empty garbage bins and cans, basements, restrooms and other places which are prone to odors caused by microorganisms. • For more information, visit www.ruhof.com.

Medline

ReadyPrep CHG cloths Medline’s FDA-approved ReadyPrep CHG cloths can help overcome the challenges of pre-operative skin prep to deliver an antiseptic agent consistently, safely and effectively. The cloths are presaturated with 2 percent chlorhexidine gluconate, and each cloth contains 500 mg of CHG to help reduce bacteria that can potentially cause SSIs and can reduce microorganisms on the skin for up to six hours after application. The large cloth is 68% bigger than the market leader and has a two-year shelf life to help reduce waste and save health systems money. • For more information, visit medline.com/pages/chg/.

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March 2021 | OR TODAY

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CE430

IN THE OR

continuing education

Safer Patient Handling Saves Nurses’ Backs

By Sheila J. Leis, MS, RN-BC t is no secret that nurses are at risk for developing disabling back injuries on the job.

In fact, nurses have long cited disabling musculoskeletal injuries as a top health and safety concern, behind only stress and overwork.

The American Nurses Association’s (ANA’s) 2016 Healthy Nurse, Healthy Nation report revealed that nearly 53% of nurses have dealt with musculoskeletal pain while on the job.1

I

The ANA supported the Nurse and Health Care Worker Protection Act of 2013 (H.R. 2480). This bill, introduced

by Congressman John Conyers (D-MI), was intended to reduce the potential for injury to healthcare workers and patients, while decreasing work-associated healthcare costs and enhancing the safety of patient care delivery.2 Injury rates among healthcare workers in hospitals and nursing homes declined in 2016, according to the U.S. Bureau of Labor Statistics.3 In spite of this encouraging trend, nurses and certified nursing assistants continue to be in the top 10 occupations for nonfatal occupational injuries and illnesses involving days away from work. Nursing assistants and orderlies/attendants ranked No. 4 in 2016 in days away from work with musculoskeletal-related injuries.3 Nurses ranked No. 9 in 2016.3

Why Is Injury Risk So High?

Several factors contribute to the high rate of injury among nursing’s aging 30

OR TODAY | March 2021

workforce. According to a 2015 survey conducted by the National Council of State Boards of Nursing and The National Forum of State Nursing Workforce Centers, 50% of the RN workforce is age 50 or older, down from 53% in 2013.4 Many older workers have had more time in healthcare to sustain an injury and may be at greater risk for a repeat injury.

Hospital staff members are caring for higher-acuity patients than they were years ago. With a greater emphasis on productivity and the perceived decreased time and staffing to perform tasks properly, nursing care providers are more likely to complete tasks without necessary assistance or equipment.

Nurses were taught to use “proper body mechanics,” which, even when used properly, are inadequate for preventing musculoskeletal injuries.5 Musculoskeletal disorders (MSDs) are also known as cumulative trauma disorders, the term referring to a syndrome caused by repetitive tasks or sustained postures that are common in nursing.6 Workers’ MSDs became a focus of research when occupational medicine began to develop as a specialty. Study findings conflicted with old beliefs and confirmed the growing suspicion that repetitive small injuries caused most MSDs. Research turned up correlations between the type and frequency of tasks performed and the number of injuries.

One study of nearly 18,000 nurses found prevalence of MSDs significantly increased with age, body mass index, and work duration, particularly with shifts of

10 hours or longer. The primary type of activity found to be related to MSDs in this study was the performance of heavy physical activities sustained for at least 10 minutes at a time.7 A meta-analysis revealed a link between high psychosocial demands/low job control with the prevalence of low back pain, and suggested stress management should be added to the treatment plan for MSDs.8 Another researcher identified the “lifetime preva-

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

Goal and Objectives The goal of this program is to provide nurses with information about safe patient handling programs and the rationale for such programs. After studying the information presented here, you will be able to: • Discuss the need for the safe patient handling initiatives.

• Describe evidence-based standards for safe patient handling and movement.

• Identify how architectural design can affect the ergonomics of patient care space.

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IN THE OR

continuing education lence” of MSD, reporting 52.7% sustaining MSD in their first 5 years of working as a nurse, and 82% reporting MSD pain in the last 12 months.9 It is now widely accepted that MSDs are a collection of conditions affecting: • Muscles • Nerves • Tendons • Ligaments • Joints • Cartilage • Spinal discs They are generally manifested by: • Low back pain • Sciatica • Rotator cuff injury • Carpal tunnel syndrome Tissue injury occurs when a person performs a task in which the load exceeds the tissue tension, leading to an inflammatory response that, when left undertreated, causes more tissue damage and formation of scar tissue. The scar tissue interferes with tissue nutrition and leads to microscopic wear and degeneration of soft tissues.10 As the number of assaults to the muscle tissue increases, the damage grows and affects larger areas, leading to: • Fibrous development • Weakness • Pain • Decreased mobility and strength Damage to spinal structures occurs as a result of compression and shear forces.

Compression forces (from lifting), anterior-posterior shear (from pushing and pulling), and lateral shear (from twisting and turning) cause microfractures of the vertebral endplates. Repetitive assaults increase the size of these fractures and lead to disc slippage, herniation, and neurocompression injuries.5

Show Me the Evidence Patient assessment and care planning are evidence-based tasks related to safe patient handling. Careful assessment of patients is the beginning of deciding which techniques and machinery would complement patient characteristics. FacWWW.ORTODAY.COM

tors to consider include how the patient functions currently including the ability to bear weight and capability to use the arms and upper body to assist with movement. These kinds of factors should be a part of a safe transfer plan, along with patient understanding and collaboration with the healthcare team that assists with transfer activities.11-13 The U.S. Department of Veterans Affairs (VA) suggests taking into account the patient and the environment when making transfer decisions. Then one can select proper equipment. Remember, those involved in lifting/transfer should have knowledge regarding: • Proper equipment use • How to maintain the equipment • Ability to ascertain if the equipment does indeed work properly • The transfer or lift plan • How to describe the process to patients and healthcare workers who will be involved in the process11 Algorithms may be very helpful tools for the lifting/transfer process. The VA has algorithms for different groups: patients in general and patients who require bariatric care. It is important to consider how a patient can be involved in the transfer process and to support the patient’s involvement in mobility.11,13 Nurses and therapists should create plans for transfer considering: • The risks involved • Equipment needed • The number of participants needed • Any particular special needs such as sling type They should communicate this information to those who will be participating in the activity.11,13 Refer to an organization’s policies and procedures for guidance regarding how often assessments should be made and plans should be revised.

Unit safety leaders A safety leader can be developed according to a train-the-trainer approach

known as “super users.” A super user is a person with leadership skills on the unit who has expertise in related areas of nursing practice. The super user should have the authorization and responsibility for employing and continuing a current patient care program by advancing the practice and safe application of the plan by staff. Regarding safe patient lifting and transfers, the unit safety leader:11 • Assists in the evaluation and selection of proper patient care devices • Assists in decisions about ergonomic factors of the plan • Educates on ergonomic tenets and addresses unit safety concerns • Trains (and retrains, if needed) employees on new and current equipment • Assesses compliance/application of the program • Evaluates the progress and effects of the program • Acts as a liaison with the equipment manufacturer/vendor to address concerns related to equipment function or supplies The Occupational Safety and Health Administration recommends that healthcare facilities “implement methods to control hazards such as lifting, transferring, and repositioning patients” as part of a safe patient handling program. Furthermore, the agency suggests a “zero-lift” program, minimizing the risks associated with manual patient lifting with the use of specialized equipment and lifting tools.13

Lift teams Having a trained team of personnel who use the equipment for higher-risk lifts and transfers is one strategy for decreasing lift and transfer injuries. A team approach decreases the number of staff members working with the highest risk lifts and transfers, and also provides a way to help manage the factors related to injuries.14 Requiring the use of equipment to help with lifts and transfers for March 2021 | OR TODAY

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continuing education

The 8 Evidence-Based Standards for Safe Patient Handling12 1. Establishing a culture of safety, which includes ensuring safe levels of staffing, creating a nonpunitive environment, and developing a system for communication and collaboration 2. Implementing and sustaining a safe patient handling and mobility program 3. Incorporating ergonomic design principles to provide a safe environment of care 4. Selecting, installing, and maintaining safe patient handling technology 5. Establishing a system for education, training, and maintaining competence 6. Integrating patient-centered assessment, care planning, and technology 7. Including safe patient handling in reasonable accommodations and postinjury return-to-work policies 8. Establishing a comprehensive evaluation system

high-risk situations (barring emergencies) provides yet another approach to managing the factors of possible injury. Additional advantages to lift teams include: • There is a significant decrease in cost related to patient handling injuries.

• Staff with injuries might be able to resume working or keep working as long as there is restricted exposure to high-risk activities.

• One 800-bed hospital reported that back and shoulder injuries among nurses fell 70% since implementation of the lift team.14 • Patient safety is enhanced due to an experienced team approach for transfers and lifts.

Teamwork and appropriate equipment enhance staff and patient safety.

The positive results of lift teams depend on many aspects including: • Selective hiring • Education and training • Support from supervisory staff • Policies that describe the elements of the program • The facility’s awareness that the team exists • Quality and quantity messaging about the team’s achievements13,14,15

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Technologies and equipment Achievements of a safe lift and transfer program and its corresponding policies can be strongly related to choosing the correct technology and machinery based on judgments, thoughts, and feedback of personnel who will actually be using the equipment.10 For vertical transfers (the patient starts or ends in a seated or standing position), equipment includes:16 • Manual floor-based lifts with cranks or levers. These are the oldest basic lifting devices. They have a base that is maneuvered across the floor and may be appropriate for units on which manual vertical transfers are rare, but they contribute to repetitive-motion injuries when a nurse uses them often.16 • Powered floor-based lifts. These lifts eliminate the need for staff to adjust a crank or lever to bring patients on or off a surface. Some powered floor-based lifts help move patients within the environment. More sophisticated lifts help position patients once they are on a bed or in a chair. Some models can transfer patients from cars or trucks and can be invaluable for EDs or other outpatient areas.16

•

Ceiling-mounted patient lifts.

This type of equipment is fixed or attached to ceilings or associated wall mounts. Downsides to these lifts include the expense of preparing ceilings and walls for the equipment as well as the fact that the equipment cannot practically be transferred from place to place where it may be needed.16 All of these lifts require slings, and the selection of the appropriate sling is as important as selecting the appropriate type of lift for the job to be done.

• Gait/transfer belts are used with patients who need a limited amount of support to stand, transfer, or ambulate. The recommended style has handles to provide stability for the caregiver during the activity.16,17 • Transfer boards are a bridge between one surface and another, and facilitate independent or partially dependent transfers (for example, bed to chair or wheelchair to toilet). A special transfer board, known as a pivot disc, is used to help a patient do a standpivot transfer.16 • Nonpowered standing assist devices provide a secure device (for example, a pole that cognitively intact patients with reduced leg or abdominal strength can use to pull or push themselves up from a sitting to a standing position).

• Powered standing lifts help patients with limitations in weightbearing ability to move from a sitting to a standing position; some models even help with ambulation. They are excellent for chair-to-toilet transfers because of their maneuverability and small base.16 For lateral transfers (transfers from one flat surface to another): • Friction-reducing devices are made of smooth, slick-surfaced WWW.ORTODAY.COM

IN THE OR

continuing education synthetic fabrics that help patients with limited or no ability to move on their own by reducing the amount of effort required on the part of the caregiver to perform a transfer. Handles and pull straps improve grasp and reduce the forward reach required by the caregiver during the transfer.11,17 • Inflatable lateral transfer aids are a combination of a friction-reducing device and an air mattress.

Once the special mattress-like surface is under the patient, it is inflated. Air flowing through the perforations on the underside of the mattress creates a microelevation that allows the mattress to slide with minimal effort from one flat surface to another.11 • A transfer chair is a wheelchair or dependency chair that converts to a stretcher and performs like other nonpowered mechanical lateral transfer aids.11 • Ceiling lifts with a supine sling mounted perpendicular to the direction of the bed or stretcher can also be used for lateral transfers.11 For repositioning: • A trapeze bar attached to the bed is a low-tech device that can be used for patients with strong upper bodies but limited use of their legs, which makes it difficult for them to independently position themselves in bed.

• Glide sheets, or low-friction sheets, make repositioning easier and reduce skin shearing.11 • Rotation beds and turning mattresses include rotating mechanical devices as part of the bed structure or within the mattress.

They turn patients from side to side at a set time, more often than the usual every-2-hour schedule. Rotation beds and turning mattresses generally increase patient comfort and satisfaction, WWW.ORTODAY.COM

and reduce the negative consequences of immobility and stasis.

For transporting: • Powered beds and stretchers make it easier to move a patient in the hospital and require less staff. Although expensive, these devices are essential when transporting patients in critical care and other high-acuity areas to and from diagnostic testing or other procedures.11 For special needs: • OR transport, transfer, and positioning devices have been developed. The most innovative devices replace the standard operating or radiology table and are used to transport the patient from the hospital room or holding area and help position the patient for a procedure. Others are specialized mechanical lateral transfer devices made for moving patients in and around the OR and postanesthesia care areas.11 The needs of home health, nursing home, and outpatient caregivers have also been considered. Devices that can be adapted easily to these practice environments include: • A friction-reducing device for lateral transfers • A circular pivot disc to help in proper positioning • One-way glide cushions that prevent patients from sliding out of wheelchairs • Gait belts used to ambulate or help with transferring In addition, powered and nonpowered lift equipment designed for the smaller spaces of a home or clinic is available. Medicare covers lifts ordered by a physician.

The challenges of caring for patients requiring bariatric care can be minimized with equipment designed for their additional girth and weight. The equipment includes slings and lifts to

reposition, turn, and position body parts for personal care and dressing changes.18

Safety by Design Intelligently planned settings that encourage personnel to apply ergonomically sound procedures or that enable patients to help themselves reposition and transfer with little staff intervention can greatly improve patient handling.13 Before construction begins, planners, builders, and facility administrators ought to urge clinical staff to contribute to the planning and design phases.

Participation can help to ensure that patient flow (from admittance to departure) makes sense in regard to preventing injury and also intelligent design for workflow. Mock activities can be performed to test plans, throughput, and other concepts. The design and planning teams can decide on which equipment to purchase, where to place the equipment, and other matters pertaining to safe handling.19 The size of hospital rooms has a major influence on nursing staff’s ability to use safe handling techniques. One group that has analyzed space requirements in hospitals is the Association for Health and Safety in the Workplace, Social Affairs Sector, a nonprofit, public-private group in Quebec. Using average-sized patient care equipment in a standard room and a room for patients who require bariatric care, the group performed patient transfers and other care activities with the number of staff members generally used. Based on its observations, the group issued recommendations on sizes for patient rooms, bathrooms, hallways, and doorways. The recommendations include leaving 6 feet between the door and the bed in a patient room to accommodate a floor lift and leaving 42 inches between the toilet and the wall on one side to accommodate lateral standing transfers; doorways should be 36 to 43 inches wide to accommodate bariatric equipment.20 Persons in leadership and/or manMarch 2021 | OR TODAY

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IN THE OR

continuing education agement roles should actively drive and support ways to safeguard patient handling including:2,5,13 • Generating a setting where personnel are motivated to help facilitate patient self-care and self-management strategies. An ergonomics committee might be a positive step forward.

• Creating a culture of safe patient handling • Seeking out ways the environment could be modified to promote safe handling (with personnel buy-in) • Asking staff members about their thoughts and recommendations • Embracing safe handling policies and procedures • Creating a lift team • Ensuring continuing education for safe handling (decision trees, machinery, techniques, outcomes, hospital quality indicators, compliance aspects, personal empowerment for unit-specific matters, etc.)

For years, the focus of preventing MSDs has been on proper body mechanics. However, literature over the years reveals that other strategies and approaches can help as well. Backing from administration and buy-in from managers related to equipment, planning, design, and practices — all chosen or developed with initial and ongoing staff input — is extremely important for injury prevention and the overall safety of staff and patients.

EDITOR’S NOTE: Kathleen J. Haydon, the original author of this educational activity, as well as Jennifer H. Matthews, PhD, APRN-BC, and Margi J. Schultz, PhD, MSN, RN, CNE, past authors of this educational activity, have not had an opportunity to influence the content of this version.

Relias LLC guarantees this educational activity is free from bias.

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SHEILA J. LEIS, MS, RN-BC, is a fulltime nursing faculty member at Indiana Wesleyan University in Marion, Indiana.

Her professional experience includes more than 15 years as a professional development specialist in a centralized nursing education department at an 800+-bed Magnet hospital.

References 1. Healthy nurse, healthy nation.

American Nurses Association Web site. https://anacalif.memberclicks. net/assets/Events/generalassembly2016/presentations/healthy%20 nurse%20healthy%20nation%20 -%202%20slides%20per%20page. pdf. Published October 15, 2016.

Accessed June 28, 2019.

2. H.R. 2480 - Nurse and Health Care Worker Protection Act of 2013. Congress.gov Web site. https://www.congress.gov/ bill/113th-congress/house-bill/2480.

Published 2013. Accessed June 28, 2019.

3. 2016 Survey of occupational injuries & illnesses charts package.

U.S. Bureau of Labor Statistics, U.S. Department of Labor Web site. https://www.bls.gov/iif/osch0060. pdf. Published November 9, 2017.

Accessed June 28, 2019.

4. National nursing workforce study.

National Council of State Boards of Nursing Web site: https://www. ncsbn.org/workforce.htm. Updated 2018. Accessed June 28, 2019.

5. Roberts K. Body mechanics won’t cut it: dealing with nurse back injuries. CEUFast Web site. https:// ceufast.com/blog/body-mechanicswont-cut-it-dealing-with-nurseback-injuries. Published November 4, 2015. Accessed June 28, 2019.

6. Iqbal ZA, Alghadir AH. Cumulative trauma disorders: a review.

J Back Musculoskelet Rehabil.

2017;30(4):663-666. doi: 10.3233/ BMR-150266.

7. Thinkhamrop W, Sawaengdee K, Tangcharoensathien V, et al. Burden of musculoskeletal disorders among registered nurses: evidence from the Thai nurse cohort study. BMC Nurs.

2017;16:68. doi: 10.1186/s12912017-0263-x.

8. Bernal D, Campos-Serna J, Tobias A, Vargas-Prada S, Benavides FG, Serra C. Work-related psychosocial risk factors and musculoskeletal disorders in hospital nurses and nursing aides: a systematic review and meta-analysis. Int J Nurs Stud.

2015;52(2):635-648. doi: 10.1016/j. ijnurstu.2014.11.003.

9. Chiwaridzo M, Makotore V, Dambi JM, Munambah N, Mhlanga M. Work-related musculoskeletal disorders among registered general nurses: a case of a large central hospital in Harare, Zimbabwe. BMC Res Notes. 2018;11(1):315. doi: 10.1186/s13104-018-3412-8.

10. Workplace Athletics. MSD Prevention 101. Ergonomics Plus Web site. https://ergo-plus.com/ wp-content/uploads/WA-HandoutMSD-Prevention.pdf. Accessed June 28, 2019.

11. Safe patient handling and mobility guidebook. Tampa VA Research and Education Foundation, Inc. Web site. http://www.tampavaref.org/ safe-patient-handling/implementation-tools.htm. Published January 2016. Accessed June 28, 2019.

12. American Nurses Association.

Safe Patient Handling and Mobility: Interprofessional National Standards

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CE430

How to Earn Continuing Education Credit Across the Care Continuum. Silver Spring, MD: American Nurses Association; 2013.

13. Getting a handle on handling patients safely.

American Society for Quality Web site. http://asq.org/ qualitynews/qnt/execute/displaySetup?newsID=19568.

Published December 23, 2014. Accessed June 28, 2019.

14. Patient lift team program reduces injuries and boosts productivity among nurses. Agency for Healthcare Research and Quality Web site. https://innovations.ahrq.gov/profiles/patient-lift-team-program-reduces-injuries-and-boosts-productivity-among-nurses.

Published April 14, 2008. Updated August 13, 2014.

Accessed June 28, 2019.

15. Ovayolu O, Ovayolu N, Genc M, Col-Araz N. Frequency and severity of low back pain in nurses working in intensive care units and influential factors. Pak J Med Sci. 2014;30(1):70-76. doi: 10.12669/ pjms.301.3455.

16. Baptiste A. Technology solutions for high-risk tasks in critical care. Crit Care Nurs Clin North Am. 2007;19(2):177-186. doi: 10.1016/j.ccell.2007.02.011.

17. Lloyd JD. Patient handling technologies. In: Nelson AL, ed. Safe Patient Handling and Movement: A Practical Guide for Health Care Professionals. New York, NY: Springer Publishing Company, Inc.; 2006:89-104.

18. Gillespie T, Lane S. Moving the bariatric patient.

Crit Care Nurs Q. 2018;41(3):297-301. doi: 10.1097/ CNQ.0000000000000209.

19. Villeneuve J. Physical environment for provision of nursing care: design for safe patient handling.

In: Nelson AL, ed. Safe Patient Handling and Movement: A Practical Guide for Health Care Professionals.

New York, NY: Springer Publishing Company, Inc.; 2006:187-208.

20. Villeneuve J. Architectural design to promote safe patient handling. Program presented at the 2006 Safe Patient Handling and Movement Conference; March 2, 2006; Clearwater Beach, FL.

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COVER STORY

PANDEMIC Lessons Learned

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OR TODAY | March 2021

from COVID-19

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By Don Sadler

A

little over a year ago, we were just starting to hear about a new coronavirus dubbed COVID-19. Before the end of March, a worldwide pandemic was declared that we’re still fighting today.

Now is a good time to take a look back at some of the lessons we’ve learned so far, as well as how elective surgeries are resuming and how COVID-19 could change the health care industry and perioperative practice going forward.

Capacity is Key According to Vangie Dennis, MSN, RN, CNOR, CMLSO, assistant vice president, perioperative services, with AnMed Health in Anderson, South Carolina, the issue that most affects the ability to perform elective surgeries in hospitals is capacity.

“Most hospitals are at 130 to 150 percent bed capacity because of the recent COVID surge,” she says. “So regardless of segregation of

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outpatients and inpatients and all patients being tested for COVID, there are no available hospital beds even if surgery is performed.”

Dennis believes that elective surgeries should be classified with protocols for urgency. “We cannot limit elective surgeries without impacting the long-term outcomes of patient health,” she says.

Karen Reiter, RN, CNOR, RNFA, CASC, is the CEO of DISC Surgery Center in Newport Beach, California. She says that before the recent surge, her center had gotten back up and running and “really felt we had found our groove in this crazy time.”

“However, we went into another lockdown of cases on January 5 per the CDPH,” she adds. “We are now back to restrictive emergent cases only because of the COVID surge in Los Angeles and Orange County.”

“Very few of the centers I work with stopped performing surgeries, or if they did, it was for a limited time,” says Deb Yoder, MHA, RN, CNOR, RNFA, director of

clinical operations and compliance officer for Surgical Management Professionals in Sioux Falls, South Dakota.

“The providers and local hospital were able to come together to create a list of elective urgent procedures that could be completed to meet patient care needs and not jeopardize the future health of patients,” Yoder adds.

However, most of the ASCs Yoder works with are still catching up with cases, she says.

“The hardest issue is having enough product to perform cases and meet patient needs,” she says.

“Cases are resuming but with a process of testing patients prior to procedures and working around the delay in obtaining test results.”

March 2021 | OR TODAY

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COVER STORY What We’ve Learned from COVID-19 David Hoyt, MD, FACS, the executive director of the American College of Surgeons, notes that while the health care industry has had experience with natural disasters and how they affect surgeries, the impact of something like COVID-19 was widely unknown.

“Since this all began, we’ve learned a tremendous amount about the things that are needed in place to deal with a pandemic, like ventilators and PPE,” he says. “The pandemic has also revealed the impact that this level of intense caregiving has on physicians and nurses.”

“I think it will be critical to create an after-action report in a year or so to analyze what was done right and wrong to help ensure that we have durable solutions for the next crisis like this,” Hoyt adds.

Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, the CEO and executive director of the Association of periOperative Registered Nurses (AORN), believes that one of the biggest lessons learned from the pandemic so

40 OR TODAY | March 2021

far is the need to critically assess the capacity of all the supplies and equipment that are essential to patient care in a crisis.

“This includes beds, ventilators, PPE, medications and so forth,” says Groah. “Supply chain management is critical to this process. For example, stockpiling supplies that are ready to meet the patients’ and staff’s needs and partnering with medical supply vendors to assist with the distribution of PPE.” Groah also recommends that staff be cross-trained to assist in other areas of the hospital and trained on the proper use of PPE consistent with non-crisis-level patient care.

“It’s important that capacity be able to meet the needs of patients without resorting to implementing a crisis level of care,” she says.

Yoder concurs, citing the importance of supplies and material availability and the need for less dependance on other countries for PPE and pharmaceutical supplies as one of the most important lessons learned. “The entire materials chain was broken or stretched to the point of breaking during the pandemic

and continues to be tenuous today,” she says.

One of the unintended consequences of the pandemic, says Groah, has been that the focus on prevention and antimicrobial stewardship programs was discontinued or stopped due to COVID-19. “This work will need to be restarted after the pandemic and future planning should include continued use of resources on important projects while meeting the needs of the current crisis,” she says.

In addition, short-term, pandemic-related solutions have been implemented that are not consistent with pre-pandemic accepted practices, Groah adds.

“Returning to acceptable practices will be a slow process,” she adds.

State of-the-Art Infection Control Reiter’s DISC Surgery Center was built with insight in regard to infection control.

“It features a closed HVAC system for the ASC only,” she says. “Every air exchange for the entire facility is exchanged every three minutes and each exchange goes through pre-post

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Deb Yoder MHA, RN, CNOR, RNFA

David Hoyt MD, FACS

Linda Groah

HEPA filters and is UV treated.”

“When we put this system in place the construction company joked that us and the CDC were the only places that could sustain an anthrax attack,” says Reiter.

“Now it looks like every cent that was spent was well worth it.”

The isolated cases of COVID-19 that have been picked up in the facility have never spread from one person to another because of the air systems and strict adherence to protocols, says Reiter. “I strongly believe that special air systems like the one we have should be utilized in every new ASC construction going forward.”

Groah notes that during the pandemic, there has been an increased use of telemedicine for preoperative assessments, pre- and postoperative education and postoperative patient evaluations.

“We’ve also seen greater implementation of standardized care protocols in all surgical specialties – this allows another clinician to care for the patient should the need occur,” says Groh. “The result has been optimized length of stay, increased efficiency and fewer complications.”

Hoyt believes that once everyone gets

used to doing preoperative assessments and postoperative evaluations virtually, this will become standard practice. “I don’t think it will change back,” he says. “And it could reduce costs – the studies aren’t in yet, but early indications are that it’s cheaper to do it this way.”

“I think we’re going to see a real transformation of the health care industry over the next decade,” Hoyt adds.

Looking Ahead Groah believes that pandemics will be added to the list of disasters that are addressed in future health care facility disaster plans. “Also, I believe a nationwide plan will be developed that will provide all facilities with a roadmap to cope with a disaster such as COVID-19.”

“Unfortunately, I don’t think we can ever be fully prepared for a health care crisis of this magnitude,” says Dennis.

“Going forward, we need to be better prepared to contain the infection with more aggressive mandates for protection in order to minimize the physical and economic impact on society.”

MSN, RN, CNOR, NEA-BC, FAAN

WWW.ORTODAY.COM

March 2021 | OR TODAY

41

Spotlight

By Matt Skoufalos

B

efore she embarked on a 36-year career in nursing, Kathy Beydler was a teacher. Unlike many nurses, who claim a family lineage in the profession, or may have been alongside a loved one through a protracted health issue, Beydler entered the health care field simply because she decided that she wanted a change of pace.

After graduating nursing school at Belmont University in Nashville, Tennessee, the Memphis native returned to her hometown to raise her young child, and start work at Methodist University Hospital. There she began an OR training program for nurses without any operating room experience, and became one of its first three graduates that the hospital hired into its OR unit. She credits an early mentor, Dwana Parker, with having helped ease her transition into the new assignment.

“She’d been a nurse longer than I had,” Beydler recalled. “She was very good at teaching, but tough as nails, and very patient-centered. I learned about how to take care of the patient and how to take care of family members. It’s all about empathy and recognizing how vulnerable patients and their families are.”

Maintaining an empathic, patient-centered approach to care is critical to the effectiveness of any nursing professional, and Beydler knows that firsthand, having more than once been a surgical patient throughout her time in the OR. At 30, she was diagnosed with breast cancer, and underwent surgery at the same hospital where she worked. At 34, the disease returned, and she was back in the OR. As recently as five years ago, Beydler suffered complications after a colon resection that led to four surgeries in the span of five months, two of them emergency procedures.

Those experiences demonstrated to her how anxious patients can be in a hospital, and how it felt to manage the concerns that they have when they are most vulnerable, all of which Beydler

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t On

Kathy W. Beydler

RN, MBA, CNOR, CASC, Managing Partner, Strategic Surgical Solutions

said shaped her approach both to patient care and her role in nursing leadership.

“It’s made a big impact,” she said. “I’ve been on the other end where I felt like I was a number; I’ve been on the table where people are talking over me as if I weren’t there. I see that scenario every single time in my head, without exception, when I talk to a family member [about their loved one in surgery].”

One of the most significant takeaways from her experience as a surgical patient was the work Beydler did to understand how, even with her first-hand knowledge of the surgical environment, she still walked away feeling vulnerable, almost excluded, from an intimate process involving her own body.

“People in the OR have to put up a bit of a barrier to protect themselves from what’s really happening,” she said.

“What we do in the OR, if you really step back to think about it, it’s not normal. You don’t normally go in and cut somebody open, and take part of their body out, and sew them back up.”

“We’re making a positive difference when we do that, but because we do it every day, it becomes routine,” Beydler said. “Because we do those procedures one after another, we may lose sight of the fact that these are actually people who have families who care about them.

“We have the ability to impact people’s lives either positively or negatively, but we can lose sight when we’re there,” she said. “I still remember how I felt then, and that is my driving passion.”

After recovering from those surgeries, Beydler decided to broaden the focus of her career. Her experiences as the administrator of two surgical centers and the director of a levelone trauma center helped her discover how much she enjoyed managing the financial side of the business, and Beydler also returned to school to complete her master’s degree in business administration.

Today, she is the managing partner at Strategic Surgical WWW.ORTODAY.COM

Solutions of Memphis, Tennessee, and leverages her expertise in practice consultancy to help others in the nursing field become more compassionate, thoughtful nurses.

“When I went to nursing school, I thought, ‘I’ve got a degree in education, how is this going to work?’ ” Beydler said. “But having a degree in education and a degree in nursing ties in so well together because I’ve done education at every level, and in every job that I’ve ever had.”

“Whether I’m a mentor, whether I’m a leader, whether I’m writing an article, it all comes together for me, and I’m so very thankful for that,” she said.

Beydler is fueled by a passion for practice improvement and for nursing excellence in general. Whether in coaching departments to deliver better patient care or leading surgical groups to improve their patients’ health outcomes, she applies a personal touch to leading those professionals she encounters to achieve a higher standard of excellence in their roles.

“The challenge of a leader is getting out of the way,” Beydler said. “Know your people, know your business, and know what’s important to your people. Our job is to remove the obstacles, get the staff involved and let them decide how to do it.”

When she’s not busy at work, Beydler enjoys writing, both for herself and her business, and spending time with her family. Together with her husband of 40 years, Dwain, she’s welcomed her first grandchild, whom she said is “truly my happy spot.” The same guiding principles that have supported her marriage through four decades – determination, self-examination and persistence – are the ones that have given her a professional career in health care that’s lasted nearly as long.

“Just like everything in life that’s worth having, it takes conscious effort, it takes work, and it’s never too late to learn what you’ve done wrong,” Beydler said. “Life is not going to be perfect, so you make the corrections, and you move forward.”

“As nurses, we’re hard on each other and we’re hard on ourselves,” she said. “We could give each other more grace.

You never know what people are going through, and just a word of encouragement can make all the difference in the world. Being willing to listen and being vulnerable is hard, but that’s what’s important and exhibits the humanity of health care.”

March 2021 | OR TODAY

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OUT OF THE OR fitness

Breathing for a Strong Core

By Miguel J. Ortiz reathing is literally the most important thing we do, and most people seldom think about it.

B

Each day we take about 20,000 breaths, which is about 14 thousand liters of air, and we should breathe through our stomach and not our chest. Unfortunately, we are very distracted. With a lot of stress, we forget to breathe properly causing us to use the wrong muscle groups and breathe from our chest. We should be taking around 6-12 breathes per minute, but we tend to average 16-20 breathes.

Controlled breathing techniques should be taught at childhood. Not only does proper breathing help use the muscles in your core more efficiently, but the calming stress relief and posture control gained from proper breathing will be one of the best things you’ll ever do. Here are a couple of breathing techniques that will help get you through day-to-day life and assist in strengthening your core and posture.

Because most of us are not used to breathing from our core and stomach, I recommend starting with some simple pressure or resistance. For this 44 OR TODAY | March 2021

exercise you need a pillow or a rolledup towel. Laying facedown, place the pillow under your stomach. For about 1 minute, take 5 to 7 slow breaths. On the inhale, concentrate on inflating the abdomen, you will feel your core press to slightly prop you up. On the exhale, control the tempo at which you lower yourself by slowly drawing in your navel allowing the body to sink over the pillow. After one minute, relax for about 30 seconds and repeat the routine. However, when you get to the top of the motion during the inhale, hold the breath for 3 seconds and tighten your core as much as possible, then exhale.

Next, turn over and go into bridge breathing. This particular movement will actually activate a lot more of your pelvic floor because of how the diaphragm is stretched. While lying on your back bend your knees up with your feet flat on the floor and hip width apart. When you begin to inhale, slowly lift your hips raising into a bridge position opening up your chest and be sure to squeeze your glutes at the top of this position. As you slowly exhale, roll one vertebra at a time on the way down until your back is

flat and back at the starting position.

Perform this for 1 minute, take a 30 second rest and then repeat.

I personally love these two exercises to start and end my day, but the more you practice breathing from your core the more you’ll do it throughout the day. In order to do so, you need to be conscious of your breathing.

So, the next time you’re sitting down breathe in, lightly draw in your navel (which will naturally lift the chest and posture). Slowly breathe out, allowing your posture to be maintained and be sure not to over contract your core on the exhale. When you do this, try to knock out 10 controlled breaths, break for 30 seconds and then repeat.

Enjoy your new breathing. Your core, your abs and posture will be sure to thank you.

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

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OUT OF THE OR health

Can Mammogram Screening Be More Effective?

By Peter Dizikes bout 35 percent of women get annual mammograms from age 40 onward. But the value of those screenings has been much debated, because mammograms for people in their 40s catch relatively few cases of breast cancer, generate plenty of false positive results and produce some cases of unnecessary treatment.

A

Thus, while some organizations have advocated for testing to start at age 40, in 2009 the U.S. Preventive Services Task Force recommended that women start regular mammogram screening at age 50, not age 40 – a major preventative health policy change.

But a new study co-authored

by MIT scholars identifies an important challenge in designing such guidelines: Women who start getting mammograms at age 40 may be healthier than the population of 40-year-old women as a whole – and they have a lower incidence of breast cancer than those who do not start getting tested at that age.

Therefore, simply changing age 46

OR TODAY | March 2021

recommendations is not, by itself, an optimal way to make breast-cancer screening policy.

For one thing, given that women who opt in to testing in their 40s are relatively healthier, altering those age guidelines has a relatively limited impact. At the same time, if mammogram screenings reached more women from ages 40-49, those tests would likely detect more cases of breast cancer, per screening, than they currently do. This suggests that new ways of identifying at-risk women who would benefit from screening would also be useful.

“Debates over when to recommend screening are missing a key point,” says MIT economist Amy Finkelstein, co-author of a new paper detailing the study’s results.

“There are arguments about what the costs and benefits are of screening women at a certain age, but these tend to overlook the fact that those who follow the recommendations [for early screening] differ from the rest of the population. This makes the problem more complicated. You can’t just forget human behavior and human selection when designing recommended health care

practices.”

To picture the health disparity the researchers found, suppose all women who currently start mammogram screening at age 40 shifted their first test to age 45. Now suppose an equal-size group of women with average health had been starting screening at age 40, and also shifted their first tests to age 45 as well. Both groups would see a rise in mortality due to breast cancer, but the first group would have only about one-quarter as many deaths.

“What we find in the paper is that compared to the women who don’t follow the recommendation to get a mammogram, those who do are healthier, they are less likely to have cancer, and if they do find cancer, it’s likelier to be smaller and at an earlier stage,” says Abby Ostriker, an MIT Ph.D. candidate in economics and a co-author of the study.

“Targeting screening to higher-risk groups could be more effective than general age-based recommendations, which we find attract mostly healthy women,” adds Tamar Oostrom, Ph.D., an assistant professor of economics at Ohio State University and a co-author of the study.

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The paper, “Screening and Selection: The Case of Mammograms,” appears in the December issue of the American Economic Review. The co-authors are Finkelstein, who is the John and Jennie S. MacDonald Professor of Economics in the MIT Department of Economics; Liran Einav, a professor of economics at Stanford University; Oostrom; Ostriker; and Heidi Williams, the Charles R. Schwab Professor of Economics at Stanford University.

Data Show ‘Compliers’ Are Healthier Overall, health insurance data show, about 90 percent of mammograms for middle-aged women are negative, another 9.7 percent are false positives, and just 0.7 percent are authentically positive. Previous studies have found particularly limited mammogram benefits for women ages 40 to 49. But the American Cancer Society has still advocated that women start annual screening at age 40, and the Affordable Care Act of 2010 mandates that insurers reimburse mammograms for women starting at age 40. Therefore, the percentage of women having mammograms jumps sharply from 10 percent before age 40, to 35 percent at age 40.

However, as the scholars point out in the paper, this entire debate has “primarily focused on the average impacts of mammograms,” rather than considering the possibility that those who comply with screening recommendations may make up a lower-risk group than those who do not.

To investigate this issue, the scholars drew upon multiple information sources, including the Health Care Cost Institute (HCCI), which has data about screenings and diagnoses from three insurance companies (Aetna, Humana and United Healthcare) involving 3.7 million women who got mammograms from 2009 through 2011.

The researchers also used a database from the National Cancer Institute (NCI) called Surveillance, Epidemiology and End Results

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(SEER), which provides detailed data on over 200,000 breast cancer diagnoses between 2000 and 2014 for women in 13 U.S. states, as well as demographic data about the patients. To study the impact of detection at different points in time, the researchers used a clinical model of breast cancer disease progression in the absence of treatment, which had been developed by medical researchers. That clinical model also helped the researchers approximate the overall incidence of breast cancer in the entire population, including those who are not screened.

In all, they find that 10 percent of women who start having mammograms before age 40 have a relatively high positive test rate of 0.84 percent, possibly because they experience symptoms. By contrast, only 0.56 percent of the women who start getting mammograms at age 40 test positive for breast cancer, and the number of late-stage cases among them falls by 6 percentage points compared to people who get screened before age 40.

They also considered a third group – women who don’t get mammograms even when they are recommended above age 40. Compared to this group, women who do start screenings in their 40s (whom the researchers call “compliers”), are also more likely to get other forms of preventative care, including flu shots and cervical cancer screenings, and have fewer emergency room visits for any reason. It is harder to assess the incidence of cancer for the women who do not get mammograms even when they are recommended at age 40. But the clinicians’ model enables the researchers to estimate that the cancer risk among these unscreened women is likely higher than it is among the compliers.

“This is a great example of how health economics can build off medical research, and vice versa,” Oostrom says.

Overall, Finkelstein says, “When you make age-based recommendations, it looks like the people who

are most likely to follow them are the ones for whom it’s least beneficial – which doesn’t mean it’s not beneficial, but those are not the people you most want to target.”

Better Ways to Target?

The scholars also suggest that their findings highlight the value of recent proposals by clinical researchers to target recommended screenings to higher-risk groups – potentially based on factors like the age of mothers at first birth, or genetic markers – instead of, or together with, age-based guidance. To be sure, they recognize that such methods would still require additional medical research.

More immediately, the researchers say, they would like the findings to become part of the ongoing policy discussion.

“We want to think about choice and behavior,” Finkelstein says, noting that the ways people use health care, if studied carefully, can be applied to develop robust new policies.

The researchers also hope the paper will encourage further studies of the same main issue across a range of diseases. Earlier this fall, the U.S. Preventive Services Task Force changed its recommended start age for colorectal cancer screening from 50 to 45.

“We studied mammograms, but there are other kinds of cancer screening that are also very important,” Ostriker says. “This concept that the average person is not necessarily the same as the person who elects to participate is, I think, very pervasive. And getting more attention for that is hopefully going to be helpful.”

Support for the research was provided, in part, by the Laura and John Arnold Foundation, the National Institute on Aging, and the National Science Foundation.

For more information, the paper “Screening and Selection: The Case of Mammograms” is available online at tinyurl.com/ScreenAndSelect.

March 2021 | OR TODAY

47

OUT OF THE OR EQ factor

Working With

‘Influencing’ Styles By daniel bobinski, M.Ed. wo months ago, I started a series on identifying behavioral styles. Four core styles exist. Everyone is a blend of the four styles, but there’s no need to memorize thousands of different blends. If you can identify your own and other people’s core style from the four main styles and do a little adapting, working relationships can improve and productivity can increase significantly.

T

In my previous column, I reviewed the Dominant style – people who are more task-focused and comfortable making high-risk decisions quickly.

Our focus today is on a style known as “Influencers.” Like the Dominant style, Influencers are comfortable making high-risk decisions quickly, but they focus more on people than tasks. We refer to them as Influencers because their predominant characteristic is a desire to influence others to their way of thinking.

Value to the team Those with strong Influencing tendencies are creative and optimistic problem solvers. They are naturally wired to be team players and use enthusiasm to motivate others toward goals. Influencers often have a positive sense of humor and, because they are “people” people, they’re usually good at negotiating conflict.

Ideal environment and motivations Influencers prefer a good deal of 48

OR TODAY | March 2021

people contact. They prefer a work environment in which they can share their ideas and network with others to solve problems. Doing mundane tasks alone will be very unmotivating.

Instead, they thrive when they can participate in group projects and get recognized for being part of a team.

They usually enjoy being recognized publicly for their contributions.

Best communication methods Someone with an Influencing style is an outside-the-box thinker, so they often have a lot of “what if” ideas.

It’s best to plan a little extra time to explore these ideas and allow time for general chit-chat while you’re at it.

Skipping past that and moving straight into a discussion of facts or figures without allowing for goal exploration will be a turnoff.

This means you’ll want to ask their opinion, and then expect to listen while they share it. As ideas emerge, it’s best to help core Influencers define success in practical terms and also help them set realistic deadlines.

When delegating to an Influencer, it’s best to put details in writing. They truly are “people” people, so when discussing projects, their brains often focus on the people involved, not the tasks. When Influencers do buckle down and start working on their tasks, they want to do a good job, so if the details and deadlines of what’s expected are in writing, they’ll know exactly what you want and check off the boxes so they can maintain a good relationship with you.

Other communication tips include providing testimonials from people they perceive to be important and offering extra incentives for their willingness to take a risk. Just be sure to keep your conversations positive and encouraging. If you talk down to them or over-control the conversation yourself, Influencers are likely to disengage.

In the next issue I’ll be reviewing the “Steady” 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 at 208-375-7606.

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OUT OUTOF OFTHE THEOR OR recipe nutrition

A Better Pickle: The Cure for Quick Fix Culture

By KIRSTEN Serrano veryone wants to sell you a quick fix, but the reality is health is not built by quick fixes. It is built by all the small choices you make all day every day. Informed choices are your best bet. Even picking a pickle matters. The thing is, your choice of pickle can either add to or detract from your health in a meaningful way. You make countless small decisions like this daily, and they add up to define your health story.

E

Let us look at the ingredient lists of two different dill pickles:

Illustration by Remy Thomas.

You may be thinking, what’s polysorbate 80? Why yellow 5?

What does calcium chloride do?

What is a natural flavor? Those are fantastic questions, and I am going to answer them in a minute. But the more important question may be, how do those Bubbies pickles get sour without vinegar? The answer is 50 OR TODAY | March 2021

fermentation.

If you are old enough, you may remember someone making pickles in a crock on a counter – no vinegar, no heat. Just cucumbers, water, salt and some spices in a crock that magically turn into pickles. For real.

The “magic” is industrious microbes getting to work. Naturally occurring microbes on the food and in the air convert carbohydrates into acid or alcohol – turning your cucumber into a pickle.

In case that does not sound appetizing to you, let me reassure you that humans have been using microbes to ferment foods since at least 7000 BC. You are eating fermented foods all the time. Not only does fermentation make pickles, but it is also responsible for beer, vanilla, coffee, cheese, chocolate, wine, yogurt, bread and much more.

Fermentation preserves food, makes it more digestible, increases nutrient levels and creates amazing flavors.

What we did not know, until just the past 20 years or so, is how dependent we are on microbes for our health. Active, living fermented foods are full of microbes called “probiotics.” These probiotic-rich foods help populate our gut microbiome (the microbial life in your intestinal tract). Gut health is a complex topic, but for now just know that we want to be doing everything we can to support a

healthy gut microbiome.

Back to pickles. The Bubbies pickle is a pickle and a prescription.

It has the very same ingredients in it that you would use to make pickles yourself. The calcium chloride is a mineral salt that helps keep the pickles crisp. I add a little when I make pickles at home.

The leading brand pickle foregoes the fermentation process and uses vinegar and heat to make the cucumber into a pickle. That is not terrible, but it robs us of the opportunity to get some much-needed probiotics. This pickle also has a bunch of unnecessary ingredients.

This is not a natural pickle. It is a simulated pickle. This dill pickle has no dill or garlic?! Instead, natural flavor has been added. Natural flavor does not mean dill and garlic.

It means a lab-created substance that was originally derived from a natural product – often completely unrelated to the flavor. The flavor could have 100 different ingredients, and we do not get to know what is in it. Yellow 5, derived from petroleum, is added to make the synthetic pickle more appetizing. In the European Union, foods containing yellow 5 are required to have a warning label stating that they “may have an adverse effect on activity and attention in children.”1 The

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leading brand pickle also has polysorbate 80. Its purpose is to disperse the flavoring and coloring to make this faux pickle more pickley. Why can’t it just be a real pickle?

Choosing a real, fermented pickle matters. It builds health, and it is a real food. Unlike some of the other fermented foods I mentioned (like coffee, beer and chocolate), the Bubbies pickle still contains active living microbial life, which makes it the perfect probiotic prescription.

You need to know the difference between real foods and simulated foods.

If this difference is news to you, do not feel bad. Most people cannot tell them apart either. No one is teaching us this stuff. Knowing the difference between the two pickles and why it matters is what I call food literacy. It is the knowledge you need to cut through all the quick fix chicanery and make smart choices – the kind that add up to health.

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1. Food Standards Agency. “Food Additives.” Food Standards Agency, UK Government. www. food.gov.uk/safety-hygiene/food-additives.

Kirsten Serrano is a nutrition consultant, chef, farmer, food literacy educator, and the bestselling author of “Eat to Your Advantage.” You can find out more about her work at SmallWonderFood.com.

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March 2021 | OR TODAY

51

OUT OF THE OR recipe

Sesame Ginger Tempeh Power Bowls with Quinoa and Sweet Potatoes INGREDIENTS: Pickled Pink Onions:

Recipe

• ¼ cup white wine vinegar

the

• 2 teaspoons white sugar • ¼ teaspoon salt • ½ small red onion, peeled and thinly sliced Sesame Ginger Vinaigrette: • 2 tablespoons vegetable oil • 2 teaspoons sesame oil • 2 teaspoons grated fresh ginger • 2 teaspoons rice wine vinegar • 2 teaspoons soy sauce • 2 teaspoons toasted sesame seeds Sweet Potatoes: • 1 tablespoon olive oil • 1 large sweet potato, peeled and cut into 1/2-inch slices Tempeh: • 1 package (8 ounces) Lightlife Original Tempeh • 1 teaspoon vegetable oil • 2 tablespoons soy sauce • 2 cups baby spinach or kale • 2 cups cooked tri-color quinoa, at room temperature • ½ ripe avocado, cubed • ½ cup canned chickpeas, rinsed and drained • 6 red grape cherry tomatoes, halved • 6 yellow grape cherry tomatoes, halved • ½ cup pea shoots

By Family Features

52

OR TODAY | March 2021

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OUT OF THE OR recipe

Turn to Tempeh for a Plant-Based Superfood

By Family Features s a key part of a nutritious eating plan, protein intake can be a healthy step to take. One increasingly popular way to add protein to an at-home menu is with protein-packed, plant-based foods like tempeh.

A

Tempeh’s roots date back thousands of years and originate in Indonesia. It’s an allnatural protein source made with simple, whole-food ingredients – most often fermented soybeans, water and rice – and is high in protein, packed with fiber and low in fat, sodium and calories. Tempeh is also loaded with vitamins and minerals like calcium, manganese, phosphorus and iron, and has all nine essential amino acids. Because it’s fermented, the nutrients in tempeh are easy for the body to digest.

The health benefits of tempeh, including

Sesame Ginger Tempeh Power Bowls with Quinoa and Sweet Potatoes 1. To make pickled pink onions: In small pot, bring white wine vinegar, sugar and salt to boil. Add onions and toss to coat 15 seconds.

Turn off heat and let sit 20 minutes, stirring occasionally, until onions are soft and bright pink. Set aside.

2. To make sesame ginger vinaigrette: In small bowl, stir vegetable and sesame oils with ginger, rice wine vinegar, soy sauce and sesame seeds. Pour into two small ramekins.

Set aside.

3. To make sweet potatoes: In large nonstick skillet over medium heat, heat olive oil.

Add sweet potato slices and cook, turning occasionally, 15-17 minutes, adjusting heat

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18 grams of protein per serving, are one reason to give it a try, but another is it’s easy and versatile to cook. It has a firm texture, nutty taste and can be baked, fried, steamed or grilled. Tempeh also easily absorbs marinades, spices and sauces. To prepare tempeh, cut it into cubes, strips or crumble it then toss into a stir-fry, layer it onto a BLT sandwich or simply warm a skillet and sear it until golden brown.

The possibilities for tempeh are nearly endless, and it’s also increasingly easy to find.

For example, Lightlife, founded in 1979 as “Tempeh Works,” was among the first commercial producers of tempeh in the United States. Today, it offers its Original Tempeh at more than 18,500 retail stores nationwide.

You can find recipes and where it is available near you at lightlife.com.

as necessary until tender when pierced with knife. Remove to cutting board and cut each slice into quarters. Wipe out skillet.

4. To make tempeh: Cut tempeh crosswise into eight triangles. In nonstick skillet over medium-low heat, heat vegetable oil. Cook tempeh with soy sauce until golden brown and warm, 2-3 minutes per side. Remove tempeh from pan and add baby spinach or kale; stir 1-2 minutes just until wilted.

5. To assemble bowls: On bottoms of two shallow bowls or plates, spread cooked quinoa. Top with piles of warm sweet potatoes, pickled pink onions, sauteed spinach or kale, avocado, chickpeas, grape tomatoes and pea shoots. Top with tempeh and serve with sesame ginger vinaigrette.

March 2021 | OR TODAY

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BBB TIP: CHOOSING A MEAL DELIVERY SERVICE

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ost people love the idea of ending their day with a relaxing, home-cooked family meal. With

more people wanting to stay home and avoid crowded grocery stores, meal delivery services have become popular.

Meal delivery services give consumers a more convenient way to make home-cooked dinner by delivering

nies offer organic, non-GMO or free-range meal

fresh, pre-measured ingredients and easy-to-follow

ingredients. If these are must-haves for your

recipes to your doorstep.

family, make sure the company you choose offers them.

But just like any other service, each company is different. Pricing, ingredients, and preparation require-

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Determine how much prep work you

ments vary greatly between services. You’ll need to

want. Some companies do more chopping and

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sauce-making than others. This seemingly small

your family’s needs. If the appeal of a meal delivery

difference can make a big difference in how long

subscription is learning new recipes and experimenting

each meal takes you to make.

with ingredients, you might choose one company. But if

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Contact customer service. If there ever is a

your main interest is speed and simplicity, another may

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be a better fit.

for example – you want to know you can count on customer service. Make sure there are clear,

The following tips will help you choose an ideal meal

easy ways to contact the company, even late in

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Do your research. Ask friends and family, read

the evening. Read the company’s reviews and

reviews, and check BBB.org to learn about past

keep an eye out for any indication that customer

customers’ experiences.

service is lacking.

Set a budget and check fine print. Pricing can sure the service you select aligns with your bud-

the cancellation policy. Each company is differ-

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ent, and some may have very strict policies.

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Be careful with your personal information. Most

you read the fine print.

food delivery services process payments online.

Know your skill level. Before committing to a

Make sure the company you choose is legitimate

plan, research what kind of cooking techniques

before offering up your personal information.

you’ll need to know. If a company’s recipes

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include shipping fees in their pricing. Make sure •

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vary greatly from one company to the next. Be

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Review BBB tips for shopping online. Since

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Avante Health Solutions………………………………… 49

MD Technologies Inc.……………………………………… 57

CATEGORICAL ASSOCIATION

INFECTION CONTROL

RENTAL/LEASING

AORN………………………………………………………………… 59

ALCO Sales & Service Co.……………………………… 56

Avante Health Solutions………………………………… 49

ASCA………………………………………………………………… 56

ASP……………………………………………………………………… 36

REPAIR SERVICES

CARDIAC PRODUCTS

Cygnus Medical………………………………………………… BC

Cygnus Medical………………………………………………… BC

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

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

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

CARTS/CABINETS

MD Technologies Inc.……………………………………… 57

REPROCESSING STATIONS

ALCO Sales & Service Co.……………………………… 56

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

MD Technologies Inc.……………………………………… 57

Cygnus Medical………………………………………………… BC

SIPS Consults………………………………………………………51

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

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

TBJ Incorporated……………………………………………… 24

TBJ Incorporated……………………………………………… 24

TBJ Incorporated……………………………………………… 24

INSTRUMENT STORAGE/TRANSPORT

SAFETY

CS/SPD

Cygnus Medical………………………………………………… BC

Calzuro.com………………………………………………………… 11

MD Technologies Inc.……………………………………… 57

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

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

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

MONITORS

SINKS

DISINFECTION

USOC Medical…………………………………………………… 45

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

ASP……………………………………………………………………… 36

ONCOLOGY SERVICES

TBJ Incorporated……………………………………………… 24

Cygnus Medical………………………………………………… BC

Avante Health Solutions………………………………… 49

SKIN PREPARATION

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

ONLINE RESOURCE

BD………………………………………………………………………… 7

DISPOSABLES

OR Today Webinar Series……………………………… 37

STERILIZATION

ALCO Sales & Service Co.……………………………… 56

OR TABLES/BOOMS/ACCESSORIES

ASP……………………………………………………………………… 36

ENDOSCOPY

Action Products, Inc.…………………………………………17

Cygnus Medical………………………………………………… BC

Cygnus Medical………………………………………………… BC

Innovative Medical Products……………………………21

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

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

OTHER

MD Technologies Inc.……………………………………… 57

MD Technologies Inc.……………………………………… 57

AIV Inc.……………………………………………………………… 23

TBJ Incorporated……………………………………………… 24

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

PATIENT MONITORING

SURGICAL

Sympliant………………………………………………………………13

AIV Inc.……………………………………………………………… 23

Avante Health Solutions………………………………… 49

FALL PREVENTION

Avante Health Solutions………………………………… 49

MD Technologies Inc.……………………………………… 57

ALCO Sales & Service Co.……………………………… 56

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

SIPS Consults………………………………………………………51

FLUID MANAGEMENT

USOC Medical…………………………………………………… 45

SURGICAL INSTRUMENT/ACCESSORIES

MD Technologies Inc.……………………………………… 57

POSITIONING PRODUCTS

Cygnus Medical………………………………………………… BC

FOOTWEAR

Action Products, Inc.…………………………………………17

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

Calzuro.com………………………………………………………… 11

Cygnus Medical………………………………………………… BC

TELEMETRY

GENERAL

Innovative Medical Products……………………………21

AIV Inc.……………………………………………………………… 23

AIV Inc.……………………………………………………………… 23

PRESSURE ULCER MANAGEMENT

USOC Medical…………………………………………………… 45

HOSPITAL BEDS/PARTS

Action Products, Inc.…………………………………………17

WASTE MANAGEMENT

ALCO Sales & Service Co.……………………………… 56

MD Technologies Inc.……………………………………… 57 TBJ Incorporated……………………………………………… 24

58

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