OR Today Magazine April 2021 by MD Publishing

SURGERY STARTS HERE COMPETENCIES

PRODUCT FOCUS SURGICAL INSTRUMENTS

CE ARTICLE CHARTING

LIFE IN AND OUT OF THE OR

EQ FACTOR STEADY STYLES

APRIL 2021

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OR TODAY | April 2021

contents features

THE IMPORTANCE OF TEAMWORK Communication and teamwork are keys to winning a Super Bowl. They are also vital when it comes to providing excellent care in an OR or ASC setting.

Several research organizations expect the

This course provides nurses with

Those with a strong “Steady” style are

surgical instrument markets to grow over

information about the value of laws

dependable team workers who work hard

the next few years.

and standards governing nursing

for a leader or a cause. They tend to be

documentation, legal basis for appropriate

good listeners.

MARKET REPORT

CONTINUING EDUCATION

EQ FACTOR

documentation and techniques for documenting changes in a patient’s condition.

OR Today (Vol. 21, Issue #4) April 2021 is published monthly by MD Publishing, 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290. POSTMASTER: Send address changes to OR Today at 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290. For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. © 2021

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INDUSTRY INSIGHTS

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8 News & Notes 16 TJC: Promoting Staff Safety within the ASC Setting 18 Surgery Starts Here: Competencies: Not just a checkbox; a patients’ life. 20 IAHCSMM: SPD Myth Busting Builds Better Interdisciplinary Understanding, Outcomes 22 AAMI: Research Focus: Surgical Masks, COVID-19 and Endoscope Outbreaks 24 CCI: Changes to Recertification Processes 26 Webinars: Webinar Shares Reprocessing Tips

28 M arket Analysis: Reports Predict Surgical Instrument Market Growth 29 Product Focus: Surgical Instruments 32 CE Article: Document It Right: Would Your Charting Stand Up to Scrutiny?

OUT OF THE OR

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April 2021 | OR TODAY

INDUSTRY INSIGHTS

news & notes

Xenex Announces DEACTIVATE Handheld Disinfection Device Xenex Disinfection Services Inc. has launched Deactivate, a high-powered, handheld LED device designed to quickly disinfect surfaces in confined spaces. Xenex is known for its LightStrike germ-zapping robots, which have been deployed by hundreds of healthcare facilities worldwide for no-touch room disinfection. As a result of the COVID-19 pandemic, LightStrike robots are now used in airports, schools, hotels, sports arenas, police stations and correctional facilities, convention centers, and more to quickly disinfect large rooms and areas. Recognizing the need for targeted disinfection in small spaces and compact areas, Xenex has launched Deactivate, which utilizes high-powered LEDs to create ultraviolet (UV) light proven to deactivate pathogens, including severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the virus that causes COVID-19. Deactivate does not require warm-up or cool-down time and does not leave

behind any chemical residue. Post-disinfection, the area is immediately available for use. “Our mission is to stop the pain and suffering caused by infections by destroying the pathogens that cause them. We wanted to offer an effective technology for disinfecting small spaces that are hard to clean and that’s what Deactivate provides,” said Irene Hahn, senior vice president of sales and marketing for Xenex. •

AAAHC Releases Updated Toolkit for Obese Patients According to the Centers for Disease Control and Prevention (CDC), obesity has nearly tripled worldwide since 1975 and is a “common, serious, and costly” issue. Increased obesity rates combined with an increase in the number and complexity of surgeries/procedures performed in ambulatory settings make procedural considerations for obese patients an important topic for ambulatory surgery centers (ASCs). To help ASCs implement necessary precautions and prevent negative outcomes for obese patients, the Accreditation Association for Ambulatory Health Care (AAAHC) has published a fully revised Ambulatory Procedure Considerations for Obese Patients Toolkit. “As obesity rates continue to rise, providers should be evaluating obese patients on an individual basis to determine whether they can safely undergo surgery in an ambulatory set-

OR TODAY | April 2021

ting,” said Noel Adachi, MBA, president and CEO of AAAHC. “Authored by experts in ambulatory care, our revised toolkit includes an updated evidence-based decision-guide for providers on when to move forward with ambulatory surgery and when to consider a hospital setting as more appropriate.” The comprehensive flowchart serves as a preoperative evaluation resource for providers and is based on a patient’s body mass index (BMI), the level of sedation used in the procedure, and the status of any preexisting diseases or disorders that could potentially complicate surgery. The toolkit also details up-to-date preoperative considerations for procedures involving obese patients who have recovered from COVID-19. • For more information on AAAHC, visit www.aaahc.org.

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news & notes

Guidance Helps ‘Clean Up’ Medical Device IFUs Medical device manufacturers, regulators and healthcare technology management (HTM) experts recently joined forces to solve a long-standing issue for medical device processing: confusing instructions for use (IFUs). These essential instructions explain how to properly clean, disinfect, sterilize and make the device ready for use on the next patient. This updated technical information report, TIR12:2020, Designing, testing, and labeling medical devices intended for processing by health care facilities: A guide for device manufacturers, standardizes manufacturer IFUs for the processing of clinically used medical devices and helps manufacturers understand how well the end users comprehend a device’s instructions and labeling. “Regulators have been pushing the message that end users need to follow manufacturer instructions, saying ‘Don’t make it up yourself.’ But when users look at an IFU, it can be confusing or incomplete,” explained Damien Berg, a regional manager of sterile processing at University of Colorado Health and past president of IAHCSMM. Berg co-chaired the AAMI working group that completely revamped TIR12, creating its new 2020 version. The working group determined early on that even though manufacturers and test labs have been validating IFUs all along, the conditions

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and terminology that they have used were not always an “apples-toapples” comparison to the rapidly changing environment that is the clinical setting. To create more sensical instructions and labeling, manufacturers would need a way to reference the tools, terminology and expectations of device users and regulators alike. This is where the new report comes in. “It’s a much cleaner and easier to read reference document for the manufacturers,” Berg said. “In turn, the hope is that this will allow them to get their product through the FDA easier and quicker. Then I as an end user get to use their product with clear instructions. It all comes down to proactively reducing confusion for my staff.” Initially, sterile processing managers and device manufacturers worked at this problem from different directions, added AAMI working group co-chair Ralph Basile, vice president of marketing and regulatory affairs for Healthmark Industries Company Inc. “A number of manufacturers were going through the process of rewriting their IFUs alone. They were saying, ‘If we can’t figure this out, how are customers supposed to do it?’ Around that time, the working group had turned its attention towards standardizing IFUs, so the manufacturers shared what they had,” Basile said. “We got

endusers, testing labs, and even the FDA involved and that really got this whole effort going.” An important milestone was the 2017 update of the standard ANSI/ AAMI/ISO 17664, Processing of health care products – Information to be provided by the medical device manufacturer for the processing of medical devices, which details what information must be provided to health care facilities (including instructions for pretreatment, cleaning, disinfection, drying, inspection, maintenance and functionality testing, and packaging). It also describes the validation testing that needs to be conducted to ensure each of these processes is suitable for the device. Three years after ISO 17664 was published, TIR12 now ensures that manufacturers not only know what information they need to provide, but also how to provide it. “This was an amazing collaboration of end users, manufacturers and testing labs. At one point we were comparing hundreds of different IFUs, figuring out what the commonalities were and where the gaps were,” said Berg. “Now, we’re approaching a point where we all say, ‘follow the manufacturer’s instructions’ with confidence!” •

April 2021 | OR TODAY

INDUSTRY INSIGHTS

news & notes

Ultraviolet Air Filtration System Earns FDA 510(k) Clearance Aerobiotix Inc., a manufacturer of air treatment devices for hospitals and health care, has announced U.S. Food and Drug Administration (FDA) 510(k) clearance of the Aerocure-MD medical air purification system. This system joins an expanding line of Aerobiotix technologies which utilize patented simultaneous mechanical and ultraviolet filtration to eliminate airborne contamination in clinical environments. Aerobiotix submitted independent data demonstrating effectiveness against viral and bacterial aerosols, as well as particulate contamination to support clearance. The Aerocure-MD platform is unique in that it has FDA labeling to both destroy microorganisms in the air by exposure to ultraviolet radiation and also remove particles from the air via HEPA filtration. The system is designed for mobile, highvolume air decontamination applications in health care spaces such as acute care areas, contaminated storage and handling areas, and long-term health care facilities. Unlike other ultraviolet technologies, Aerobiotix uses a shielded internal ultraviolet

system, preventing potentially hazardous exposure of personnel and material to ultraviolet rays. Aerobiotix products, including the Illuvia nonturbulent air system for operating rooms, are used globally by leading medical centers and are supported by multiple published clinical studies. •

Ambu Expands GPO Contracts Ambu Inc. has been granted national single-use endoscopy contract expansions with two U.S. group purchasing organizations (GPOs). With these expansions, Ambu is now on contract with four major GPOs in the U.S. with either a full or partial portfolio of single-use endoscopy categories available for these GPO customers. On one contract, Ambu’s aScope 4 Cysto has been added, while Ambu’s aScope Duodeno has been added on another. The expanded agreements strengthen Ambu’s position in single-use

OR TODAY | April 2021

bronchoscopes, rhinolaryngoscopes and now cystoscopes and duodenoscopes for the duration of the contracts. The aScope 4 Cysto addition expands the single-use endoscopy category of an existing contract and will be effective immediately through November 2023. The expansion enables Ambu to more broadly serve 160 acute care hospitals in the U.S. and over 2,600 total sites across more than 20 states. This expanded agreement will further accelerate growth of Ambu’s share of the single-use endoscope market by giving those ac-

counts pre-negotiated terms for Ambu’s bronchoscopy, rhinolaryngoscopy and cystoscopy products. The aScope Duodeno addition to the existing contract with another major GPO, meanwhile, provides access to Ambu’s entire suite of single-use endoscopes and will be effective through February 2022. • For more information, visit ambu.com or ambuUSA.com.

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news & notes

AORN Releases 2021 Guidelines for Perioperative Practice The Association of periOperative Registered Nurses (AORN) has published the 2021 Guidelines for Perioperative Practice with six revised guidelines. Guidelines for Perioperative Practice, published each January with online updates made available throughout the year, is a collection of 34 guidelines that provide evidence-based recommendations to deliver safe perioperative patient

care and achieve workplace safety. According to Erin Kyle, DNP, RN, CNOR, NEA-BC, editor in chief, Guidelines for Perioperative Practice, revisions in 2021 reflect the latest evidence, technologies and practice needs. Some significant revisions include guidelines for laser safety, electrosurgical safety, pneumatic tourniquet safety, instrument care and cleaning, care of the patient

receiving local-only anesthesia and specimen management. The guidelines are available in various pricing models for individuals or teams within facilities and multi-site health care systems. The purchase of the 2021 print edition comes with a complimentary registration to attend a guidelines workshop event. •

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April 2021 | OR TODAY

INDUSTRY INSIGHTS

news & notes

Data Analytics for Safe Healthcare (DASH) Announced The Joint Commission and Joint Commission Resources (JCR) Inc. have announced a new data transparency initiative – Data Analytics for Safe Healthcare (DASH). The initiative offers three business intelligence tools in the form of dashboards and performance improvement resources to power customers’ performance improvement efforts on their journey to zero harm. The three business intelligence tools include Accelerate PI (The Joint Commission), SAFER Dashboard (The Joint Commission) and Illumi-

nate Analytics (JCR). “The data DASH provides will help organizations see at a glance their greatest needs and opportunities for improvement in key areas,” says David W. Baker, MD, MPH, FACP, executive vice president for health care quality evaluation, The Joint Commission. “With DASH, health care leaders can easily see how they compare to their peers and to the performance of leading organizations.” DASH’s three business intelligence tools are or are anticipated to be

available to select Joint Commission accredited health care organizations and/or select JCR E-product customers in 2021 – spanning across ambulatory surgery center, home health and hospice, hospital and nursing care center settings for select dashboards. There is no additional fee to use DASH or any of its business intelligence tools. • For more information, visit jointcommission.org.

Activ Surgical Joins Microsoft for Startups Activ Surgical has been named a member of Microsoft for Startups – a global program that helps B2B startups successfully scale. As a member in the program, Activ Surgical will have exclusive access to Microsoft’s technologies, including Azure, as well as a streamlined path to selling alongside Microsoft and its global partner ecosystem. Activ Surgical’s participation in the program and collaboration with Microsoft will help increase opportunities for hospitals and health care systems in the U.S. and in global markets to use its newly announced ActivEdge platform. ActivEdge is an artificial intelligence (AI) and machine-learning (ML) hardware agnostic platform that

OR TODAY | April 2021

enables existing surgical systems to see in real-time what humans cannot currently see, including blood flow. ActivSight, the company’s first product to launch from ActivEdge, provides real-time views of blood perfusion without the need for the injection of dyes, as well as allowing for fluorescing of indocyanine green (ICG) dye. It works dynamically and seamlessly with any installed visualization system to provide real-time intraoperative visual data and images not currently available to surgeons through existing technologies. ActivSight has been submitted for FDA clearance and is expected to be commercially available this year. •

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news & notes

ECRI Lists Top Health Technology Hazards Hundreds of medical products have been authorized for temporary use in the past year to meet the unprecedented need for life-saving equipment and supplies during the COVID-19 pandemic. ECRI cautions that meticulous management of these Emergency Use Authorization (EUA) products is crucial to protecting patients, health care workers and hospital operations. ECRI, an independent nonprofit organization, listed the complexity of managing devices that have been authorized through the EUA process at the top of its 2021 Top 10 Health Technology Hazards report. “Emergency Use Authorization is a lower standard than is used to assess safety and effectiveness through FDA’s normal clearance process, and it requires more work on the part of the hospital,” says Marcus Schabacker, MD, Ph.D., president and chief executive officer of ECRI. Through its EUA process, FDA can green-light previously unapproved products – or new indications for previously cleared products – as acceptable for use during an emergency. Hospitals need to watch for safety and performance issues, monitor the device’s authorization status daily and know what to do with the device when the EUA ends, according to ECRI experts. “Failing to do so could create safety risks for patients and liability risks

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for the hospital,” adds Schabacker, because once the EUA designation ends, the legal protections that support the use of EUA devices on new patients vanish. EUAs can be ended at any time. For example, in August 2020, FDA revoked the EUA for a class of protective barrier enclosures after they were found to increase health care workers’ exposure to airborne particles, rather than limiting exposure. “We’re concerned that hospitals might not have adequate processes in place to deal with this complex challenge,” says Schabacker. “Our new guidance can act as a roadmap for hospitals and health systems broadly. Additionally, through our alerts tracking reports, we are providing actionable advice. If more support is needed, ECRI is here to help.” Now in its 14th year, ECRI’s Top 10 Health Technology Hazards identifies health technology concerns that warrant attention by health care leaders. ECRI’s team of biomedical engineers, clinicians and health care management experts follows a rigorous review process to select topics for the annual list, drawing insight from incident investigations, reporting databases and independent medical device testing. ECRI’s full list of health technology hazards for 2021 includes: • EUA device management: Complexity of managing medical devices

with COVID-19 Emergency Use Authorization • Drug name auto-display: Fatal medication errors can result when drug entry fields populate after only a few letters • Telehealth adoption: Rapid adoption of telehealth technologies can leave patients and data at risk • Imported N95-style masks: May fail to protect health care workers from infectious respiratory diseases • Consumer-grade devices: Relying on consumer-grade products can lead to inappropriate health care decisions • UV disinfection: Hasty deployment of UV disinfection devices can reduce effectiveness and increase exposure risks • Software vulnerabilities: Vulnerabilities in third-party software components present cybersecurity challenges • AI in diagnostic imaging: Artificial intelligence applications for diagnostic imaging may misrepresent certain patient populations • Remote operation risks: Remote operation of medical devices designed for bedside use introduces insidious risks • 3D printing quality: Insufficient quality assurance of 3D-printed, patient-specific medical devices may harm patients •

April 2021 | OR TODAY

INDUSTRY INSIGHTS

news & notes

UVDI-360 Room Sanitizer Inactivates SARS-CoV-2 in Five Minutes UltraViolet Devices Inc. (UVDI) has announced that its UVDI-360 Room Sanitizer achieved greater than 99.99%, or 4log10, inactivation of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) in five minutes at a distance of 12 feet (3.65 meters). Testing on the coronavirus strain that causes the COVID-19 disease was conducted by Innovative Bioanalysis, a CAP, CLIA, and BEI-recognized BSL-3 certified laboratory (CA, USA). The Centers for Disease Control and Prevention (CDC) has indicated that the COVID-19 disease can be spread by both surface and airborne transmission of SARS-CoV-2. The testing parameters were carefully selected to be indicative of rapid whole room disinfection in hospitals. The UVDI-360 Room Sanitizer has previously been proven to help prevent healthcare-associated infections and to inactivate over 35 pathogens, including human coronavirus (229E), in over 10 peer-reviewed published clinical studies and independent laboratory testing.

OR TODAY | April 2021

“We hope this important testing can lend confidence and comfort to health care professionals working bravely and tirelessly to beat COVID-19.” stated Peter Veloz, chief executive officer, UVDI. “Specific to use in hospitals for whole room disinfection, we believe that proving rapid inactivation of pathogens at distances of 8 feet (2.44 meters) and 12 feet (3.65 meters) is the best marker for in-facility performance. Independent confirmation of effectiveness against high-risk pathogens is a common sense, yet critical step to verify disinfecting claims for UV devices.” “Building on our deep science-based evidence demonstrating the UVDI-360’s effectiveness against high-risk pathogens, including coronaviruses, we feel the health care professionals we serve globally deserve proof against the specific SARS-CoV-2 viral strain causing COVID-19,” added Dr. Ashish Mathur, vice president of innovation and technology, UVDI.•

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news & notes

Exactech Launches Next-Generation Technology for ExactechGPS Exactech has announced the launch of next-generation hardware and software for its ExactechGPS guided personalized surgery system. These new developments further advance the only navigation system available for knee and shoulder replacement surgery, which serves as the foundation of the company’s Active Intelligence technology platform. ExactechGPS now features wireless connectivity for more interconnected data, case management and technology integration. In addition, new proprietary camera technology provides state-of-the-art visibility and stability, allowing straightforward incorporation into surgeonspecific and operating room workflows. With the addition of these design features, ExactechGPS continues to

be available with no capital expense, allows the surgeon full control and accessibility within the sterile field, and maintains a small footprint which makes it amenable to ambulatory surgery centers. ExactechGPS currently supports both knee and shoulder applications, with future expansion planned. These next-generation ExactechGPS upgrades will occur throughout 2021 at no cost. ExactechGPS is a foundational technology that powers Exactech’s Active Intelligence platform. The company is aggressively expanding this portfolio of uniquely accessible smart solutions to help surgeons engage with patients and peers, solve challenges with predictive tools and optimize the way they perform surgery. •

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INDUSTRY INSIGHTS CCI TJC

Promoting Staff Safety within the ASC Setting By Elizabeth Even, MSN, RN, CEN here are few areas where precision and accuracy matter more than within an operating room (OR). It is difficult to identify another location that is under such intense time pressure and scrutiny. In ambulatory surgical centers (ASC), surgical procedures must be correct, and they must be time efficient. When patients enter an ASC, they are likely amid hundreds of thousands of dollars of lifesaving equipment, medications and instrumentation. However, even the best equipment and technology available is useless without a highly trained health care team standing around the OR table. Competently trained and experienced staff is invaluable for any organization, and many would argue that staff members are the most precious resource in health care. Afterall, without staff, an ASC loses its ability to care for patients. In surgical environments where patient conditions may change rapidly and care decisions must be made quickly, proficient staff are an even more critical component.

Because of the incredibly important role staff play in health care, ensuring a safe work environment is vital. In addition to suffering from scheduling 16

OR TODAY | April 2021

crunches, health care organizations also must endure the cost of lost staff due to both turnover and time off following a workplace injury. The price tag can be staggering. According to Becker’s Hospital Review health care injuries cost health care organizations billions of dollars every year in addition to millions of days of lost work. The article continues stating that the health care industry reports a significantly higher number of injuries compared to other areas, with OR injuries landing high on the list. Lengthy cases, awkward postures, sharp instruments and heavy instrument trays are just a few common culprits lurking in an ASC that can cause staff injury. As discussed, the OR can be like a pressure cooker at times. When individuals are pressed for time, they naturally resort to finding quick ways to “get it done.” In the OR, “getting it done” may mean holding a patient for positioning during surgery instead of seeking an alternative that may be more time consuming. Fact is that in many situations, it is quicker to move a patient from a stretcher to an operating table with the help of a few staff members or to position them by holding them yourself than to utilize alternative options. However, taking these short cuts is precisely what leads to injured staff and ultimately costs health care organizations big dollars down the road. Needlestick and sharps injuries are also very common and occur at a higher rate in an OR than

other areas of the hospital. According to the Centers for Disease Control and Prevention (CDC), hospital employees are victims of about 385,000 sharps injuries each year. According to the Association of periOperative Registered Nurses (AORN), 30 percent of the estimated needlestick and other sharps-related injuries occur in an OR, specifically while health care staff pass suture needles and scalpels. The Joint Commission standards and elements of performance, located in the Infection Control chapter of The Ambulatory Care Manual, can assist health care organizations assess their own risks for injury and determine how to best mitigate those risks. One area that is frequently assessed for risk is the physical environment of the surgery center. The Environment of Care Chapter of The Joint Commission’s Ambulatory Care Manual, guides organizations as they establish and maintain a safe, sanitary and functional environment. The standards address a broad range of environmental issues from handling hazardous materials and equipment maintenance to fire drills and ensuring suitable lighting. According to The National Institute for Occupational Safety and Health (NIOSH) hierarchy of controls elimination and substitution of a hazard is the most effective way to ensure workplace safety. Engineering controls are third on the hierarchy and can be highly effective at protecting employees and patients in a way that does WWW.ORTODAY.COM

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not affect workflow or take any extra effort on the part of the employee by ensuring that the environment is appropriately designed and maintained. Examples such as negative airflow in rooms and HVAC filtration units keep staff safe by minimizing their respiratory exposure while caring for patients with respiratory infections. In addition to the obvious and measurable physical and environmental risks, mental health can be at risk in an ASC as well. The COVID-19 pandemic has highlighted the incredible importance of mental wellness of all staff. Much research has been published about culture of safety in health care and never has that been more important than while working on the frontlines during a pandemic. “We are all in this together,” has been the sentiment communicated in many articles written about health care staff in various facility departments throughout this past year. But what is meant by “culture of safety?” To some, the phrase may conjure up an image of an irate surgeon throwing instruments during a tirade. However, it is much larger and much smaller than that at the same time. Ignoring or belittling co-workers, grueling scheduling and intimidation are all less obvious ways that staff may create a toxic work environment. The Joint Commission’s standards and elements of performance address the importance of maintaining a culture of safety in the Leadership chapter in the Ambulatory Care Manual. AdditionWWW.ORTODAY.COM

ally, establishing a culture of safety is communicated in number of Quick Safety articles, Sentinel Event Alerts, blog posts and updates on The Joint Commission website. Patient safety is at the very heart of The Joint’s Commission mission. The foundation for safe patient care is ensuring staff are reporting to a safe work environment. Health care leadership can accomplish this with a well-developed and maintained physical environment and safe equipment, clear policies and procedures to guide care as well as a strong culture of safety in which all employees feel empowered to speak up when they have concerns. Joint Commission standards and elements of performance in the Ambulatory Care Manual can aid organizations on their journey to excellence and zero harm. True leaders know that every single member of the care team from the front desk receptionist to the surgeon performing the case all play an imperative part in the overall care delivery every day. We truly are all in this together.

Elizabeth Even, MSN, RN, CEN, is the associate director, clinical standards interpretation, division of healthcare improvement, The Joint Commission.

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Competencies Not just a checkbox; a patients’ life. By Brandon Huffman, BS, CIC, CRCST, CIS, CHL have been blessed in my career to have met many awesome operating room technicians and nurses who selflessly volunteer their time and skills to help in sterile processing. As we know all too well in this industry, operating room and sterile processing staff are consistently understaffed. As a sterile processing manager who regularly had trouble tackling the workload with the staff I had, I welcomed help with open arms. Who doesn’t love teamwork right?

Though the help was more than I could ask for to elevate our ability to meet the demand of surgical caseloads, I quickly felt the quality of work decline through incident reports and surgeon feedback. Our wonderful OR techs and nurses were great at assembling trays. They absolutely knew every instrument in the pans. However, what they didn’t know was the bigger picture of what actually takes place during tray assembly – instrument inspection. We had issues with instruments that were misaligned at the tips. Instruments that were missing parts. Instrument stains, pitting and rust that were all missed during the assembly and inspection process. And, I couldn’t help but realize, it was my fault! I graciously accepted the help I was offered with18

OR TODAY | April 2021

out ensuring a full competency was in place. As the leader of the department I contributed to a disservice with not only my helpers and surgeons, but also to the patients we served. Too often, I come across processes in hospitals and departments that are left unchecked. It’s easy to find competency issues, just listen when a health care professional tells another, “That’s not the way I do it.” Whenever I hear that simple phrase, I immediately question why there could be disparity in how a standard process is completed or whether a standard process exists at all? We are all unique people, and diversity is something we should cherish, but when it comes to medical practice, deviation from a single standard can be life threatening. Regardless of the accreditation body your organization chooses to follow, competencies are a required and inspectable item. Competencies should be evaluated upon hire, and periodically at certain intervals. They are also required when you have other employees float to your department or if you have traveler positions filled for short periods of time. All personnel working in your department need validated competencies proving their ability to complete the task or job correctly. Think of competencies as a preflight checklist. Before pilots taxi a plane for takeoff, there is a checklist of items and tests to run beforehand. And

this does not even cover the extensive hours of classroom and flight time a pilot previously completed. Pilots take every precaution to ensure the plane they take off the ground will successfully land on the ground (on its wheels) without killing the hundreds of passengers on board. We as health care professionals should be ensuring the jobs we perform comply with appropriate steps and measures that are free from gaps in competency. Are you picking up what I’m throwing down? Making sure your staff and coworkers have been appropriately validated for competencies is imperative. Maybe you are now on board and lack competency tools in your organization. You might be asking, “Where do I even start?” Well, let me introduce you to my best friend Google. All jokes aside, one thing you must understand is you do not have to reinvent the wheel. There are so many competency checklists on the Internet today it will amaze you. My recommendation is to seek some already prepared checklists and use those as inspiration to build your own. Every hospital and department is different. Tailor your checklist to your specific situation. Another option is working with a professional association. You can even join a local chapter through your association and network with other professionals who have successfully created or implemented competency checklists in their organizations. WWW.ORTODAY.COM

SUBSCRIBE Lastly, I would like to say that once you have implemented competencies, don’t forget about them! Competencies should be living, breathing documents that change when the work or processes change. I would regularly evaluate my staff to ensure their skills and knowledge of processes were still relevant, and if not, we would revisit the competency checklist for a refresher. They can also be scheduled into your weekly in-service times throughout the year as refreshers and ongoing competency updates. In closing, you can do this! And now that I got that motivational push out of the way I will also remind you that you must do this, because it’s required. Happy competency building!

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IAHCSMM

SPD Myth Busting Builds Better Interdisciplinary Understanding, Outcomes By Tony Thurmond, CRCST, CIS, CHL irtually every discipline with the health care environment has its share of “sacred cows” and myths – and many of those have been passed down year after year to employees. Those myths eventually are then viewed as acceptable practice because they convey “the way things have always been done in the departments.” Many myths abound in the sterile processing department (SPD) and their lingering presence creates confusion that can erode interdisciplinary relationships and, worse, lead to errors and misjudgment that impact patient safety and customer service.

Many health care professionals can recall certain practices that originated as a myth and eventually were deemed as a “truth” that continued to be followed in the days, weeks, months and years that followed. Often, many employees blindly ascribe to those myths without giving deeper pause as to why. In some cases, we may be so busy that we simply don’t challenge those practices (or we simply trust that certain practices are acceptable because others haven’t challenged them). But it’s critical that we understand how myths can be detrimental to safety and success inside and outside the SPD – and we must work to dispel them. Daily, sterile processing profession20

OR TODAY | April 2021

als have an opportunity to instruct and guide their teammates and customers toward a better understanding and drive proper practice in the name of safe patient safety. It’s a responsibility that must be acted upon. It won’t always be easy, especially because SPD’s customers may have also grown accustomed to the myths as well – but it’s essential that sterile processing professionals stand their ground through any resistance and stay committed to separating fact from fiction. What follows are some issues that I believe present an opportunity for deeper exploration and better understanding: � Sterile processing staff should be “all knowing.” Many sterile processing professionals have faced the situation where they pulled every item on a physician’s preference card, but then the operating room (OR) reports everything was not there. Perhaps sterile processing professionals have been told something like this: “Dr. Smith uses [such and such] item for every case, and you should know this.” Or perhaps the SPD receives a call and is told, “I need one of those blue gadgets that attaches to the instrument I opened.” It’s always a challenge when those in the SPD receive a call for an instrument, but the device in need isn’t referred to by its proper name. � SPD lost our instruments. The myth that the SPD loses instru-

mentation has been going on for more than my 36 years of working in the surgical/sterile processing realm. My favorite thing to hear from OR staff is, “I know that when I put everything in the basin after the case, it was there. We don’t lose instruments.” Items mysteriously disappear daily along the trail from the OR to the SPD. At a former facility, we ordered replacement Allis clamps/forceps at a rate of about 80-100 per month. We addressed this issue during the OR huddle and heard comments like, “we never lose instruments,” even though a scrub technician stated they used clamps frequently to hold tubing and cords onto the drapes (and then admitted the clamps were probably being thrown out with the drapes). Missing instruments also frequently arise from careless instrument handling and rapid surgical suite turnover. Along with rapid turnover, it’s rarely taken into consideration the time needed to properly gather the used instruments, perform point-of-use cleaning and organize instruments in a way so they are not lost or damaged. � It does not take that long to process that instrument. It’s not uncommon for sterile processing professionals to receive a call from the OR stating an instrument or tray they just used for a previous case is needed for the next case WWW.ORTODAY.COM

INDUSTRY INSIGHTS

IAHCSMM

(and “by the way, the patient is in the room, so I need it now.”) This type of rushed request occurs more frequently than it should. But it’s essential that sterile processing professionals never rush any processing steps because doing so not only goes against standards, guidelines, policies, procedures and best practices, it sets patients up for infection risks or other harm. Instrument processing (and diligent inspection to ensure no bioburden remains on devices and/or devices function properly) takes time. Shortcuts or “rush jobs” must never be considered an option, and it’s essential that SPD customers (the OR and other procedure areas) understand what’s required and never allow (or request) processes to be rushed for the sake of time. What follows are some of the most effective ways I’ve found for dispelling myths and incorrect beliefs: � Emphasize education. Education is always the first step is combatting misconceptions and false assumptions. Sterile processing professionals know they must follow Association for the Advancement of Medical Instrumentation standards and they know that the Association of periOperative Registered Nurses standards give guidance for the OR nurse. They also know that surgical technologists are guided by the Association of Surgical Technologists and the National Board of Surgical Technology and Surgical Assistants. All these organizations give guidance for each critical team WWW.ORTODAY.COM

member and if they are studied and reviewed closely, all three speak of the proper care and handling of instrumentation, point-of-use instrument care and the proper design of preference cards in order to meet the needs of the surgeon and the patient. They also address proper sterilization methods and requirements. Knowing the correct process and knowing more about one another’s processes will be help solidify better working relationships and dispel myths. � Commit to proper practice. Proper practice requires a disciplined approach to our work each day, and for every case and every instrument. This is an expectation we should have for ourselves, our teammates and our customers every day. Studying SPD customers’ guidelines will prepare sterile processing technicians for situations that may arise. It will also help them address and correct processes and then share that knowledge with the customer. I inform my customers that I reviewed their organization’s guidelines and then I share with them the location in those guidelines to support my reasoning and share knowledge. It’s helpful to also share how their guidelines and practices interact with sterile processing and its own guidelines. � Work together: Creating a stronger bond with those in the OR is a best practice that can be achieved more easily than one might expect because both departments have a great deal in common. Many of

us are entrenched in our practices because it’s simply the way we were taught; however, many of the veteran teachers developed practices and habits that weren’t always based on guidelines and standards. Guidelines are ever-changing. We must reach out to our customers and build an understanding of one another’s needs, requirements and standards. It’s good practice for the SPD to invite their customers to the department to show them their challenges (and use that as an opportunity to explain why we cannot meet the quick turnover demands because they conflict with IFU, policies, procedures, standards and best practices). And those in the SPD will also benefit by meeting with their OR teammates to better understand their needs and challenges.

Conclusion Lingering myths in the workplace can jeopardize patient safety and erode trust and teamwork. Reviewing and understanding guidelines that impact both the SPD and OR – and then engaging in interdisciplinary education – will help dispel myths, set more realistic expectations, promote standardsbased best practices and deliver better outcomes for the patient. Tony Thurmond, CRCST, CIS, CHL, serves as Central Service Manager at Dayton Children’s Hospital. He is also Past-President of the International Association of Healthcare Central Service Materiel Management. April 2021 | OR TODAY

INDUSTRY INSIGHTS CCI AAMI

RESEARCH FOCUS:

Surgical Masks, COVID-19 and Endoscope Outbreaks ith the demand for respirators

W exceeding supply during the

pandemic, many facilities are reusing single-use masks. It is a good thing then, that researchers continue to up their game when it comes to sterility assurance, as detailed in three recent articles in AAMI’s peer-reviewed journal, Biomedical Instrumentation and Technology (BI&T).

Dry Heat Decontaminates Surgical Masks and Single-Use Respirators A research team based out of the microbiological quality and sterility assurance department at Johnson & Johnson have determined that dry heat processing is “an appropriate method for repeated single-use respirator and surgical mask decontamination.” The researchers confirmed that exposing a used mask to 176°F (80°C) for two hours sufficiently reduces a wide spectrum of Mycobacterium species and clears the equipment for additional use over the course of a single hospital or laboratory shift. Interestingly, the effectiveness of this method was found to fall off around the 20th cycle, limiting how frequently a facility may choose to reuse masks. Naturally, the researchers warn that soiled surgical masks and respirators are not fit for reuse. “The dry heat process presented in this article should only be applied to visibly clean single-use respirators and 22

OR TODAY | April 2021

surgical masks, with a focus on inactivating microorganisms remaining after use while preserving functionality,” the authors write. Read more at: https://bit.ly/3cUqDne.

Important Definitions for Face Mask Processing Reusing a mask that is, by definition, “single-use” can be confusing. Several of the J&J researchers who oversaw the dry heat experiments also set out to clarify key terms for sterility assurance departments during these unusual times. In a review of academic literature and online commentary, the researchers outlined key definitions for “decontamination,” “disinfection” and “sterilization.” For instance, they highlight that “decontamination” has a slightly different definition

in the U.S. verses how it is used internationally. Because of this, the researchers concluded that possible interpretations for “decontamination” may be too broad and, at times, may imply a level of clean that is impossible to achieve with common processing practices. Taking things further, they highlight that “even low-level disinfection processes, defined as killing most vegetative bacteria, some viruses and some fungi would be considered effective against SARS-CoV-2.” Thus, if the point of mask processing during the COVID-19 pandemic is to stop the spread of SARS-CoV-2, defining all effective cleaning processes as “disinfection” may help prevent confusion. Read more at: https://bit.ly/3rARGrO.

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INDUSTRY INSIGHTS

AAMI

BAC-VIS with widefield and confocal fluorescence microscopy is used to observe bacterial cells on inoculated endoscope end cap material and O-rings. Panels A and C are controls.

Highlighting Potential Outbreak Sources Even with hospitals focused on keeping the SARS-CoV-2 virus at bay, bacterial contamination remains a concern. Improper processing of endoscopes has been associated with several multi-patient outbreaks. That’s why a team of researchers from the Food and Drug Administration’s Center for Devices and Radiological Health and Healthmark Industries recently developed a new technique for visualizing where contamination may reside in a medical device even after being cleaned. “Most published studies have focused on overall contamination rather than locating the sources and design features related to contamination,” the authors wrote. “Therefore, developing

approaches for imaging bacteria on processed device parts is important.” Their paper outlines a simple four-step protocol for a stain test that detects bacteria on endoscopes or scope parts. The BAC-VIS procedure allows for concentrations of bacteria remaining on a cleaned device to glow brightly for fluorescence imaging, showing researchers where contamination may occur. These results could help lead to better cleaning procedures, device design and other preventive action. Read more at: https://bit.ly/3rhjAZO.

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INDUSTRY INSIGHTS CCI

Changes to Recertification Processes By James X. Stobinski, Ph.D., RN, CNOR, CSSM (E) s the CEO of CCI, I often interact with perioperative nurses about their professional development needs. When nurses are unhappy with changes to our programs those telephone calls and messages often come to me. These calls provide useful feedback to CCI. We exist to meet the professional development needs of perioperative nurses. Our biggest contributions to the profession are our certification programs. Recertification is a necessity with certification processes, but it is also a source of frustration for some because of recent changes. In this column, I will provide some background information on recertification processes for CCI credentials – such as CSSM and CNOR.

First, it is important to note that the recertification processes for all of our credentials are shaped, in large measure, by our accreditation agencies; the Accreditation Board for Specialty Nursing Certification (ABSNC) or the National Commission for Certifying Agencies (NCCA). Just as health 24

OR TODAY | April 2021

care facilities must maintain accredited status to be financially viable so must CCI maintain accreditation status for its programs. In addition, recognition of nursing certifications by the ANCC Magnet facility recognition programs and many state boards of nursing are dependent on accreditation status. CCI, as an organization, is not accredited. Our certification programs are each individually accredited. Our programs must comport with the standards of ABSNC and NCCA. These standards are revised periodically, and these revisions ultimately lead to changes in how CCI certifications are operationalized. The ABSNC standards for examination-based certification programs were revised in 2019-20 and the NCCA standards are under revision at present with the public comment period being open in early 2021. In general, each of these organizations have strengthened their standards on quality assurance, the separation of test development processes from the sale of products and, most importantly, in recertification processes. Where formerly accreditation standards on recertification were focused on recordkeeping processes

and security there is now an emphasis on the maintenance of competency in recertification processes. CCI must now provide evidence that our recertification processes facilitate the maintenance of competency for our certificants. The long-term reliance on the use of continuing education (CE) has drawn increasing scrutiny from accreditation agencies. Recertification processes based solely on the use of CE are no longer the accepted norm with certifications. For CSSM certificants, the most significant change, beginning in 2021, is that there is no longer a recertification assessment requiring in-person testing. We now have a reflective learning exercise that is encouraged in ABSNC Standard 13 and is consistent with the seminal report from the Institute of Medicine (US) Committee on Planning a Continuing Health Professional Education Institute (2010). The CCI credentialing team can assist with the reflective learning forms and placement in the files of each certificant. For the CNOR credential, we continue our gradual, years-long transition from a CE-only recertification option to the professional development points system supported by the CCI WWW.ORTODAY.COM

Infusion Pump Support & Power Solutions Learning Management System (LMS) based on the LearnUpon platform. These learning activities, which allow the use of some CE, are available without charge to all active certificants and are integrated with the AORN CE recordkeeping system. Also, effective January 1, 2021, there is no longer an option for any CCI certification to recertify by again taking the certification exam. We expect that future standards revisions will impact our recertification programs and we will use a variety of channels to update stakeholders. A good source of information is the recently initiated live Facebook sessions, Thursday Thoughts, Ask the CEO where I answer certificant questions in a live format. I look forward to working with and receiving input from our CCI certificants.

References Accreditation Board for Specialty Nursing Certification. (2021). ABSNC Accreditation. Accessed February 6, 2021 at: https://www.absnc.org/. Institute of Medicine (US) Committee on Planning a Continuing Health Professional Education Institute. Redesigning Continuing Education in the Health Professions. Washington (DC): National Academies Press (US); 2010. Available from: https://www.ncbi.nlm.nih.gov/books/NBK219811/

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

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April 2021 | OR TODAY

INDUSTRY INSIGHTS

news & notes webinars

WEBINAR SERIES

Webinar Shares Reprocessing Tips Staff report he OR Today webinar series continues in 2021. The most recent webinar “Take a Deep Breath: Reprocessing of Laryngoscopes and Bronchoscopes” attracted 546 registrants. It was sponsored by Advanced Sterilization Products (ASP) and eligible for one (1) continuing education (CE) hour by the California Board of Registered Nursing.

This 60-minute webinar featured Senior Manager of Commercial and Clinical Education Regina Hammond and Senior Clinical Education Consultant Janet Moran. They provided a review of airway devices, including proper handling and associated reprocessing guidelines. The webinar also touched on some of the challenges and options for reprocessing these devices, including high-level disinfection (HDL). This analysis covered the following: define the terms laryngoscope

OR TODAY | April 2021

and bronchoscope; identify when and why airway devices are utilized; review common organisms associated with airway devices; and examine reprocessing options for airway devices and discuss the barriers to properly reprocessing airway devices. Attendees provided feedback via a survey that a question about the OR Today webinar series. “As a patient safety technician, I train people how to perform HLD. I think this webinar was very informative and really helps visualize the critical points when using equipment and HLD,” said R. Irizarry, DHI patient safety technician. “Today’s webinar on reprocessing laryngoscopes and bronchoscopes had great information on what we, as sterile processing professionals, need to know. It was eye opening on types of scopes, uses, cleaning methods and different types of equipment that could be used to complete the cleaning, disinfection

and sterilizing steps of each scope. Thank you to the presenters and all involved in putting together the information for this webinar,” said L. Hazel, sterile processing supervisor. “Great presentation and very informative. Excellent for new to field and seasoned sterile processing techs,” said G. Schneider, CSR SPD Tech 3.

For more information, visit ORToday. com/upcoming-webinars. Thank you to our sponsor:

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April 2021 | OR TODAY

IN THE OR

market analysis

Reports Predict Surgical Instrument Market Growth Staff report here are different types of surgery including open, minimally invasive and robotic to name a few. There are also many reports on the various different surgery markets, including the different types of surgical instruments.

One thing that all have in common is that the research organizations behind the reports expect the surgical instrument markets to grow over the next few years. The group Verified Market Research (VMR) predicts growth in the overall surgical instrument market. The VMR report includes information about surgical sutures and staples, handheld surgical equipment and electrosurgical devices. The VMR report states that the surgical instruments market was valued at nearly $945 billion in 2019 and is projected to exceed $1.5 trillion by 2027, growing at a compound annual growth rate (CAGR) of 6.54% from 2020 to 2027. Grand View Research (GVR) predicts growth in two surgical instrument markets. “The global hand-held surgical 28

OR TODAY | April 2021

instruments market size was valued at $3.82 billion in 2017 and is expected to exhibit a CAGR of 7.1% from 2019 to 2025,” GVR states. In a separate GVR report, additional growth is predicted. “The global surgical equipment market size was valued at $9.32 billion in 2020 and is expected to grow at a CAGR of 9.8% from 2021 to 2028. Large unmet surgical needs, growing health care costs, rising geriatric population and increasing surgical volume are the key factors projected to drive the market growth during the forecast period,” a GVR report that was publishing in January 2021 states. “The long-term cost comparison study of medicine therapy with surgery revealed that early surgery is considered more cost-effective as compared to continuous medication. Patient awareness about the cost benefits of early surgical intervention is increasing with efficient patient counseling during physician visits.” The “Global Surgical Instruments Market - Forecasts from 2020 to 2025” report has been added to ResearchAndMarkets.com’s offering and also predicts growth. “The global surgical instruments

market is estimated to increase with a CAGR of 5.78% from a market size of $53.9 billion in 2019,” the report states. “The global surgical instruments market is projected to surge at a significant growth rate in the forecast period owing to the high prevalence of cardiovascular diseases in the world. These include coronary heart diseases, and rheumatic heart diseases among other cardiac diseases driving the market demand in the forecast period.” “The growing global geriatric population is further propagating the market demand with the surge in ageassociated diseases requiring surgeries for treatment further promoting the improvement in the quality of a patient’s life. The growing adoption of minimally invasive surgeries is considered to be one of the major drivers where surgical instruments in various robotic and non-robotic surgeries are fueling the market demand leading to the sales of surgical instruments,” the report continues. An Allied Market Research report states that the global surgical equipment market was valued at $31.7 billion in 2019 and is estimated to reach $44.4 billion by 2027.

WWW.ORTODAY.COM

IN THE OR

product focus

Healthmark

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April 2021 | OR TODAY

IN THE OR

product focus

McGan Technology MM513 Electrosurgical Insulation Defect Detector

McGan Technology’s MM513 Electrosurgical Insulation Defect Detector is a compact, handheld, battery-operated unit that tests the integrity, such as pinholes, cracks or defects, of the insulation of electrosurgical instrument in order to prevent inadvertent tissue burns which may occur during electrosurgical instrument procedures. Recent standards changes address the new testing requirements. •

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The Orca Smoke Evacuation Pencil is the latest Bovie smoke evacuation solution, a brand synonymous with electrosurgery. The Orca is a powerful, fully integrated, ergonomic, low-profile device providing optimal control and better protection for operating room personnel. The Joint Commission’s Quick Safety Issue 56 December 2020 lists specific actions organizations should take to help patients and staff reduce the dangers of hazardous surgical smoke plume. Orca provides up to 55% greater smoke plume clearance than the leading competitor at an economic price point. It delivers quality and value combined in one device. •

OR TODAY | April 2021

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IN THE OR

continuing education

Document It Right: Would Your Charting Stand Up to Scrutiny?

OR TODAY | April 2021

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IN THE OR

continuing education By Julie Smith Jonson, JD, BSN, RN rom the first day of nursing school until graduation, students learn the importance of documentation. However, in practice, nurses can find themselves too busy, tired, or uncertain about what to chart. In these litigious times, nurses should think carefully about what a jury would decide when looking at their documentation if a patient claims that an injury is due to their negligence.1

Your patient’s chart is a legal document that describes all their interactions with you and other caregivers. Your documentation must provide a complete and accurate accounting of their condition and the care you provided.2 If you are asked to testify in a legal action, you may need to recall details that occurred months or even years ago. Without a complete, accurate, and legible medical record, you may be unable to defend yourself against allegations of improper care. Your documentation can discourage a plaintiff from pursuing a legal claim or can provide the fuel for a lawsuit.3,4 Most lawsuits involving nurses are civil cases that attempt to prove a nurse’s negligent care resulted in injury to a patient. The law defines negligence as failure to provide a patient with the standard of care that a reasonably prudent nurse would exercise under the same or similar circumstances.5,6 To prove that a nurse was negligent, the patient’s attorney must prove these four elements: • Duty. Usually, the duty is established when the nurse agrees to provide care to the patient and to follow an acceptable standard of care. • Breach of duty. A breach of the duty is a negligent departure from the established standards of care. It is the failure to do what a reasonable prudent nurse would do in the same or similar circumstances. WWW.ORTODAY.COM

Relias LLC guarantees this educational program free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See Page 39 to learn how to earn CE credit for this module.

Goal and Objectives The purpose of this course is to provide nurses with information about the value of laws and standards governing nursing documentation, legal basics for appropriate documentation, and techniques for documenting changes in a patient’s condition. After studying the information presented here, you will be able to: • Provide the legal definition of nursing negligence • Describe four characteristics of legally credible charting • Describe two charting practices that can lead to legal problems

ausation. Causation is the apC parent relationship between the breach of the duty and the harm or injury to the patient. A nursing negligence cause of action requires proof that the failure of the care was the immediate cause of the injury. • Damages. Damages occur when the patient suffered physical or psychological injuries.5,6 If you face an allegation of negligence or improper conduct, your documentation can make or break the case. Your contention that you provided appropriate care is weakened significantly if you did not document or if your documentation does not show that you met the standard of care. Without such documented evidence in the medical record, you must rely on your ability as a witness to convince a judge or jury that you provided appropriate care despite your failure to •

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IN THE OR

continuing education document the care you provided.5 Charting errors and omissions are a significant source of liability risk for nurses. During a trial, the patient’s attorney will use documentation to try to prove that the standard of care was not met. A complete and accurate medical record is crucial because appropriate documentation provides evidence that you met the standard of care.6

Laws and Standards The type of nursing information that appears in a medical record is determined by standards developed over the years by state laws, the nursing profession, and accrediting organizations such as The Joint Commission. The U.S. legal system has helped nurses know what must be present in a patient’s chart to conclude that patient care documentation is accurate and appropriate.6 Each state has enacted a nurse practice act (NPA) that authorizes an individual to practice as a registered nurse if the applicant meets specific criteria. Further, laws or administrative rules in each state outline documentation issues, such as handling of records, falsification of records, and confidentiality.6,7 Regardless of your work setting or nursing specialty, you must document care based on the requirements of your state’s NPA. For information on your state’s NPA, contact the National Council of State Boards of Nursing. Documentation principles apply to all charting systems and formats.8 In addition to observing laws governing documentation, you must adhere to professional standards, such as those established by the American Nurses Association (ANA).6,7 If you practice in a nursing specialty area, you must be familiar with and demonstrate adherence to documentation standards developed by your specialty organization. The commission publishes widely accepted professional and documentation standards. Although The Joint Commission does not mandate a particular format for documentation, it does require each 34

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accredited healthcare facility to adopt a format that conforms to Joint Commission standards.1,3 The ANA’s and The Joint Commission’s standards are much more stringent than state laws. ANA standards of nursing practice require that documentation be based on the nursing process and that it should be ongoing and accessible to all members of the healthcare team.1,3 Because ANA standards reflect a national practice consensus, they carry a great deal of weight in court.1,3,6 You also must follow documentation policies as established by your employing facility. Most healthcare facilities develop their internal documentation policies and procedures based on state law, professional nursing standards, and The Joint Commission requirements. For example, your facility’s documentation policies should identify how often documentation should occur, which staff members are responsible for charting in each part of a patient’s record, and what charting techniques and procedures are acceptable.4,6 However, if your facility’s standards are less strict than those of your NPA, you must adhere to the higher standard of your state’s NPA.6,7

Sources of Documentation Standards • • • • •

State NPA and administrative code or rules National professional standards Specialty nursing organization standards The Joint Commission standards Standards of your employing facility

Effective Documentation Certain legal basics form a foundation for effective documentation. The saying “If it wasn’t documented, it wasn’t done”

is as valuable today as it was when you learned it in nursing school. In addition to organizing your documentation based on the five steps of the nursing process (assessment, planning, nursing diagnosis, interventions, and evaluation), your charting should leave no question in a future reader’s mind that you continuously assessed your patient’s condition and carefully monitored their progress. Nursing documentation that contains misspelled words or grammatical errors can lead lawyers and jurors to conclude that the nurse is uneducated or careless.3,5 The following examples of legal cases emphasize the importance of nursing documentation. In one case, a federal court found that a hospital violated the Emergency Medical Treatment and Active Labor Act (EMTALA) by discharging a patient from the ED before the emergency medical condition that brought her to the ED had been stabilized. The patient had undergone gastric bypass surgery 15 months before, and presented to the ED twice in the same day with worsening abdominal pain. The patient was given Ativan, Haldol, and a soap suds enema, and discharged home, even though her abdominal pain was still 8 on a scale of 1-10. The same evening, the patient went into cardiac arrest at home. She returned by ambulance and resuscitated, but died the next day after a second cardiac arrest at the hospital. The cause of death was ruled septic shock from peritonitis due to an internal hernia. In ruling that the hospital had violated EMTALA, the court relied in part on the nurse’s note in the chart of pain 8/10 at the time of discharge as proof that the patient was still suffering from the emergency medical condition that brought her to the ED in the first place.9 Similarly, a New York appellate court relied on ED nursing documentation in sustaining a jury’s verdict in favor of a hospital in a case involving a fall on hospital premises. In that case, an individual sued a hospital for negligence, claiming she tripped and fell because there was

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continuing education a hole in the sidewalk on the hospital’s grounds. The individual received treatment for her injuries in the ED of the same hospital. In the ED, the patient told a nurse a different story regarding how she sustained her injuries, namely that she fell forward when someone bumped into her while she was bent over unlocking her bicycle. The nurse documented this version of events in the patient’s chart at the time of the incident, and the jury believed this version of events at trial. 10 A Louisiana court recently refused a hospital’s motion for summary judgment and permitted a family’s wrongful death lawsuit to go forward, in part because of a nursing assessment finding that the patient required a specialty bed that the hospital never provided. In that case, a patient was admitted to a rehab facility for treatment of long-term respiratory problems. On his admission assessment, a nurse practitioner found pressure ulcers and determined he needed a specialty mattress on a standard-size bed, as the patient was 6 feet, 3 inches tall and weighed 225 pounds. The facility never provided the specialty mattress. Instead, the patient was propped up in a smaller hospital bed with pillows to keep his feet from dangling over the footboards. Five days into his stay, the patient was found on the floor in his room after sustaining a hematoma to his chest that later required surgery. The patient died two weeks later from complication of the hematoma. The Court of Appeal of Louisiana let the family’s case go forward even absent the medical panel review normally required for healthcare malpractice cases in Louisiana, finding, “[i]t is not a matter of specialized professional judgment to recognize that a hospital patient needs to be situated in a bed that is appropriate to the patient’s height and weight.”11 Another Louisiana appellate court upheld a jury’s finding of partial fault and sustaining a large verdict against the hospital for injuries an ED patient sustained when the patient fell and struck his head after administration of pain medications. WWW.ORTODAY.COM

The patient presented to the ED for left shoulder pain after falling from a horse. After obtaining his vital signs, a nurse gave the patient an injection containing Dilaudid and Phenergan while he was leaning against a sink. Although the nurse cautioned the patient that the injection could make him sleepy, she left the room apparently without instructing him about the safety precautions he should take, such as sitting or lying in a safe position. The nurse also failed to document in the chart that she had instructed the patient on the appropriate safety precautions to take following pain medication administration. Accordingly, the appellate court found no error in the jury’s finding that the nurse had deviated from the applicable standard of care.12 Recently, nursing documentation was key to a hospital’s avoidance of liability in a medical malpractice action in Illinois after the patient who wore upper and lower dentures choked on food and died while receiving medical care from a hospital following eye surgery. The patient’s daughter claimed that the hospital was negligent in part for failing to adequately monitor the patient postoperatively and for allowing her to eat without ensuring that her dentures were in her mouth. The jury returned a verdict in favor of the hospital. On appeal, the appellate court affirmed the trial court verdict. In doing so, the appellate court opined that the nursing documentation clearly supported the assertion that the nurses were not negligent. The chart documents showed that the dentures were in the patient’s mouth and that she was alert, oriented, clear in speech, and exhibited no objective evidence of cognitive impairment when she ate breakfast and choked.13 To help ensure legal credibility, ensure your charting is timely, accurate, truthful, and appropriate. Timely documentation means documenting care as soon as possible after it is provided. Although charting intervals will vary depending on the healthcare setting, regular charting entries demonstrate that you are checking your patient’s condition frequently.6

Do not wait until the end of your shift to document when you may not recall important details or may eliminate potentially important information because of time constraints. Accurate documentation means that you document the facts about patient care. Chart only what you see, hear, smell, or feel. Document only the care that you personally provided. Depending on your facility’s policy, document only care provided by an unlicensed assistive staff member that you have observed or evaluated directly. Write specific, accurate descriptions. For example, charting “Bright red blood 18 cm in diameter on bed linens” is much more specific than charting “Bed soaked with blood.”6 Do not use meaningless expressions such as “patient had a good night” or “appears” or “seems.” Follow your agency’s policy when using abbreviations. If unsure about standard abbreviations used by your facility, spell it out. Abbreviations on The Joint Commission’s official “Do Not Use” list should be avoided.3 Truthful documentation means avoiding assumptions and documenting only what you have observed. Appropriate documentation refers to committing to writing in a patient’s chart only statements you would be comfortable showing in public.4,6 Follow your facility’s documentation policies about issues such as late entries, legible charting, record confidentiality, blank lines, approved abbreviations, cosigning, and patient refusal of treatment. Document any safety precautions you implement, such as putting up side rails. Keep comments about other staff members, allegations of inadequate care, or references to staffing problems out of the patient’s medical record. Issues such as these found in a patient’s chart can be a red flag to lawyers and jurors.3 Once litigation has begun, you should not add information to a patient’s medical record. The patient’s attorney can use handwriting experts to determine the time at which various entries were made. If you suspect that another healthcare professional has made illegal changes April 2021 | OR TODAY

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continuing education

Examples of Illegal Tampering with Medical Records6 • • • • • •

Adding to another person’s note Destroying the patient’s chart Not recording important details Recording false information Writing an inaccurate date or time Adding to previous notes without indicating that the note is a late entry

to a patient’s chart, notify your nursing supervisor. Never change your notes if requested to do so by a colleague.6 Evidence of tampering with a patient’s chart not only is illegal, but it can cause the entire medical record to be inadmissible as evidence in court.6 The sidebar “Examples of Illegal Tampering with Medical Records” shows examples of illegal tampering or alterations to the medical record. You also may be subject to charges of falsification of records and fraud if you document care that has not been provided. Charting medication administration, dressing changes, or other treatments in advance all constitute falsification of records.6 The only component of the nursing process that may be documented before it is executed is the plan of care. All other observations and activities must be charted only after you access or evaluate the patient or implement an intervention.1,3,6 When you write your initials on a medication record, your initials indicate that the medication has been given, not just removed from the drawer. If you place your initials on the record before giving the patient the medication, you are exposing yourself to legal risk. If your facility uses a charting by exception (CBE) format, you will need to take extra precautions.6,14 In a CBE system, only exceptions to expected observations are charted. Because it may be several years before a lawsuit occurs, CBE may make it difficult to demonstrate that you provided appropriate care, especially if a patient develops complications. Because minimizing documentation makes it difficult to provide details, you will need to use well-designed flow

OR TODAY | April 2021

sheets in a CBE system. If the CBE documentation does not give a clear, accurate description of the patient’s condition, write it in a narrative note. If you are asked to testify several years later, you will be able to reconstruct an accurate picture of your patient’s condition.6,14 Although the CBE system saves valuable time, legal experts advise institutions to develop their system carefully and to use quality controls to ensure the system is working successfully.6 Certain types of charting actually increase your legal risk, such as failing to clearly describe situations that are out of the ordinary.6,15 Another documentation practice that increases risk is expressing a negative view or animosity toward a patient. Describing a patient’s behavior as uncooperative, difficult, or manipulative (or referring to the patient in a sarcastic manner) alerts the patient’s lawyers that a nurse did not respect or value the patient.15 Although using a negative label when referring to a patient may reflect a nurse’s frustration, think of the impact of a negative term written in a chart projected on a screen in a courtroom. You should describe patients’ behaviors in a factual and impartial manner.

Critical Incidents Critical incidents often are the basis for legal actions against nurses and hospitals. In many instances, the precipitating event that results in a lawsuit is poor communication and documentation.15 Documenting care as you provide it is especially important when you are charting in an emergency. If possible, ask another nurse to record events as they occur during the emergency. If you do not own a recorder, keep a running log of notes rather than trying to rely on your memory to reconstruct events after the emergency. (See “Documenting in Emergencies.”) You place yourself at great legal risk when you do not assess or monitor patients regularly or when you do not report a significant change in a patient’s condition. Common occurrences in which nurses have been held liable for failure to observe and report include situations in which a patient’s condition undergoes a rapid change, such as after surgery or during labor, after the patient has suffered an injury while in the facility, and when the patient has known self-destructive tendencies.6 Accusations of failure to adequately observe and monitor a patient can be substantially countered by accurate, detailed documentation.6 Numerous legal cases involve a nurse’s failure to notify the physician about changes in a patient’s condition. These cases often are extremely serious, resulting in death or permanent disability.6 As a nurse, you have a duty to intervene on your patient’s behalf. Frequently, your intervention consists of contacting the physician about a change in the patient’s condition and carrying out whatever

Documenting in Emergencies6,7 Make sure your documentation addresses these issues: The patient’s condition before the emergency The patient’s condition when the emergency began When the emergency occurred When the physician was notified What interventions were used and when they were started How the patient responded to the interventions

• • • • • •

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Organizing Your Reporting Data

Patient’s history: present illness or surgery, medications, significant comorbidities. Assessment: • Complete set of vital signs • Change in level of consciousness • Changes in perfusion as indicated by skin color, oxygen saturation, and urine output • Pain out of proportion to the diagnosis or procedure • Unusual behavior (irritability, hallucinations, agitation, sense of impending doom) • Change in a wound or drainage status • Relevant diagnostic test results

therapy the physician prescribes. However, your legal obligation as a patient advocate goes beyond carrying out prescribed treatment. If, in your professional judgment, you believe physician orders place a patient in jeopardy, you must intervene on behalf of the patient and clarify the treatment plan with the physician.4,6 Some recent malpractice cases have hinged on whether the nurse was persistent enough to notify the physician or to convince them of the seriousness of the situation. Nurses who fail to continue to question inappropriate orders by contacting a nursing supervisor or going up the chain of command can be liable for failure to intervene because the intervention was below what is expected of them as patient advocates.6 If a change in a patient’s status warrants notifying the physician and a potential change in the treatment plan, you must be able to communicate essential information in a clear and logical manner that expedites understanding and intervention.1,3,6 Communication is more difficult by telephone than in person because it eliminates nonverbal cues that enhance communication. Therefore, when communicating via telephone, you must communicate information in a logical and organized way that creates a “word picture” for the physician.15 On weekends or on second or third shifts, your communication may be with an on-call physician instead of the patient’s primary physician. As this individual may not be familiar with the

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patient, you must clearly summarize the patient’s background before describing the problem.15 The sidebar “Organizing Your Reporting Data” outlines a way of organizing data before physician contact. Do not apologize for calling the physician, and do not make them guess what you really mean. Some nurse experts report that there is evidence that nurses continue to use indirect communication and defer to physicians to avoid conflict.16 You must be clear about why you have called rather than giving the physician a list of findings for them to interpret.6 Document each time you phone a physician, even if you do not get through to them.6 When you do talk to the physician, chart the details of your message and the physician’s response.4,6 Be sure to document the name of the physician to whom you spoke. If you believe the physician is not responding appropriately, you will need additional documentation as a legal safeguard.4,6 Note specifically the details you reported, the time you called, the time new orders or no orders were received, and additional actions you take.4 If you do not note the time you called, allegations could be made later that you failed to obtain timely medical treatment for the patient. Always note in the chart the specific change in the patient’s condition or diagnostic test result that prompted your call to the physician. If you are reporting a crucial lab result, such as a high glucose level (but do not receive an order for

intervention), be sure to verify with the physician that they do not want to give an order. Your charting should note: “Dr. Green notified of blood glucose of 220 mg. No orders received.” Reducing your legal risk is important in today’s healthcare climate, in which patients are sicker and more likely to experience poor outcomes. Documentation that reflects the nursing process, including competent assessment, frequent observation, timely and accurate reporting, and using the chain of command, if necessary, often will protect the nurse from accusations of negligence, even when there is a poor outcome.15 Your documentation should tell a story. Your patient’s medical record and what you have documented in it is the single most important tool available to a nurse facing a charge of negligence.3 Legally credible documentation provides an accurate written record of the care your patient received and evidence that you met an acceptable standard of care. It tells anyone who reads it that you did all that was expected.4,6 By learning your state’s NPA, following professional standards for documentation, and adhering to your facility’s policies and procedures, you can provide patients with quality nursing care while protecting yourself and your employer from legal action. EDITOR’S NOTE: Maureen Habel, MA, RN, a nurse author residing in Seal Beach, California, and Catherine E. Jordan, MSA, RN, LNCC, a senior consultant at VantagePoint HealthCare Advisors in Hamden, Connecticut, were previous authors of this CE activity, but have not had an opportunity to influence this edition. Relias LLC guarantees this educational activity is free from bias. JULIE SMITH JONSON, JD, RN, BSN, is a Registered Nurse with Access Health and Of Counsel with the law firm Montgomery, Rennie & Jonson, LPA in Cincinnati.

April 2021 | OR TODAY

References 1. Meyers V. Defending yourself through documentation. Am. Nurse Today. 2014;9(2). https://www.americannursetoday.com/defending-yourself-throughdocumentation/. Accessed July 23, 2019. 2. Austin S. Stay out of court with proper documentation. Nursing. 2011;41(4):24-29. 3. Maryniak K. Documentation for nurses: Legalities of documentation. Western Schools Web site. https://www. westernschools.com/nursing/courses/ documentation-for-nurses%2C-3rd-edition-----n1882/. Published Oct. 23, 2018. Accessed July 23, 2019. 4. DiLeonardi BC, Miller-Hoover SR. Professional nursing documentation.

RN.com Web Site. https://lms.rn.com/ getpdf.php/2163.pdf . Accessed July 23, 2019. 5. Iyer P. 24 nursing documentation mistakes that could get you sued. StudyLib Web Site. https://studylib.net/ doc/8780171/24-nursing-documentation-mistakes-that -could-get-you-sued#. Published 2014. Accessed July 23, 2019. 6. Guido GW. Legal and Ethical Issues in Nursing. 6th ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2014. 7. Yokum RF. Documenting for quality patient care. Nursing. 2002;32(8):58-63. 8. Lockwood W. Documentation: Accurate and legal. http://www.rn.org/ courses/coursematerial-66.pdf. Updated

Clinical Vignette Bob Bryan, RN, is working the evening shift at a rehab facility. The patients he is caring for include Mrs. Jorgensen, 70, who underwent total hip replacement; Mr. Caldwell, 45, who is a paraplegic from a motorcycle accident; and Mrs. Lowe, 80, who has congestive heart failure and dementia. 1. At 19:15, Mr. Caldwell requests oral pain medication. Which of the following documentation practices regarding administration of pain medication is considered falsification of records? A. C harting an assessment of Mr. Caldwell’s need for pain medication B. C harting that Mr. Caldwell is given medication in advance C. C harting that Mr. Caldwell is given medication immediately after it is given D. C harting Mr. Caldwell’s response to the pain medication 2. To protect himself from litigation when caring for Mrs. Lowe, Bob should ensure that his documentation includes: A. All safety precautions. B. Mrs. Lowe’s activity level. C. Mrs. Lowe’s food intake. D. The use of only approved abbreviations.

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May 2017. Accessed July 23, 2019. 9. Emergency department: Nurses discharge patient still in pain, EMTALA violation found. Legal Eagle Eye Newsletter for the Nursing Profession Web site. http://www.nursinglaw.com/EMTALAviolation.htm. Published Feb. 2, 2017. Accessed July 23, 2019. 10. Fall on hospital premises: Nurse documented the facts correctly. http:// www.nursinglaw.com/fall-hospital-nurse. htm. Published Feb. 2, 2017. Accessed July 23, 2019. 11. Hospital bed too small: Court sees ground for family lawsuit. Legal Eagle Eye Newsletter for the Nursing Profession Web site. http://www.nursinglaw. com/hospital-bed-small.htm. Published

3. At 20:40, while eating a snack, Mrs. Jorgensen complains of shortness of breath. Her vital signs at 18:00 were BP 126/83 mmHg, pulse 86 beats per minute, and respirations 14 breaths per minute. Now, her vital signs are BP 90/62 mmHg, pulse 118 beats per minute, and respirations 24 breaths per minute. The following information is important for Bob to document: A. C hanges in vital signs and patient’s complaint of shortness of breath B. C hanges in vital signs, patient’s complaint of shortness of breath, the type of snack the patient was eating, and an immediate call to the patient’s physician C. C hanges in vital signs, patient’s complaint of shortness of breath, and an immediate call to the patient’s physician D. An immediate call to the patient’s physician 4. Four years have passed since Mrs. Jorgensen experienced a pulmonary embolus after her other hip replacement surgery. Her family is suing the physician and nurse for negligent care. Which statement in Mrs. Jorgensen’s medical record may place Bob at legal risk? A. “20:40 — Notified Dr. Brown of change in patient’s condition.” B. “20:40 — Patient complaining of shortness of breath.” C. “20:40 — Sudden change in patient’s vital signs (note specifics).” D. “Called MD to report a change in patient’s condition.” WWW.ORTODAY.COM

CE510 March 3, 2017. Accessed July 23, 2019.

How to Earn Continuing Education Credit

12. Patient falls after narcotic injection: Jury finds patient and nurse equally at fault for injuries. Legal Eagle Eye Newsletter for the Nursing Profession Web site. http://www.nursinglaw.com/nurse-license-revocation. pdf. Published March 2017. Accessed July 23, 2019.

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

13. Caldwell v. Advocate Condell Medical Center, 2017 IL App (2d) 160456 (July 24, 2017). Retrieved from www.illinoiscourts.gov/Opinions/AppellateCourt/2017 /2ndDistrict/2160456.pdf. Accessed July 23, 2019.

Deadline

14. Smith LS. How to chart by exception. Nursing. 2002;32(9):30. 15. Carelock J, Innerarity S. Critical incidents: Effective communication and documentation. Crit Care Nurs Q. 2001;23(4):59-66. 16. Manojlovich M, Frankel RM, Harrod M, et al. Formative evaluation of the video reflexive ethnography method, as applied to the physician-nurse dyad. BMJ Qual Saf. 2019 Feb;28(2):160-16. doi: 10.1136/ bmjqs-2017-007728.

Courses must be completed by 7/29/2022 3. If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer. 4. Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test. 5. All users must complete the evaluation process to complete course. You will be able to view a certificate on screen and print or save it for your records.

Accredited Clinical VignettE ANSWERS 1. Answer: B, Charting any medication, treatment, or other intervention in advance of administering it is considered falsification of records. Only the plan of care may be documented in advance. 2. Answer: A, Because of her dementia, Mrs. Lowe is at high risk for a fall or other injuries. Although the nurse should document activity level and food intake, and should always use only approved abbreviations, charting specific safety precautions, such as side rail placement, demonstrates that the nurse is individualizing care for this at-risk patient. 3. Answer: C, Charting sudden changes in vital signs, a patient complaint of shortness of breath, and an immediate call to the physician are essential factors to document. The type of snack the patient was eating at the time of this incident is not relevant unless the patient has a known allergy to a specific food. 4. Answer: D, This entry does not specify the name of the physician called or the time of the call. This omission will make it impossible for the nurse to prove that he called a specific person at a certain time. WWW.ORTODAY.COM

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

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Nurse.com You can take this test online or select from the list of courses available. Prices subject to change.

Questions or for a complete listing of our courses Phone: 877-843-8374 Email: nursesupport@relias.com

April 2021 | OR TODAY

COVER STORY

T H E I M P O RTA N

TEAMWO

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NCE OF

ORK

BY DON SADLER

ny successful sports team knows the importance of everybody on the team working together. Tom Brady received most of the accolades for the Tampa Bay Buccaneers’ recent Super Bowl victory and won the MVP Award. Yet, he would be the first to say that the Bucs’ suffocating defense and superior offensive line play helped make the team victorious. It’s the same in the operating room environment. Surgeons are sometimes viewed as the “quarterback,” so to speak. But the best surgeons know that it takes teamwork on the part of everyone to help ensure a successful patient outcome. This includes surgeons, perioperative nurses, the sterile processing department, the environmental services department and more. Poor teamwork among these and other departments can lead to a host of problems including surgery delays, cancellations, excessive callouts, tension and a lack of optimism and energy among staff, surgeon and staff dissatisfaction, and poor patient outcomes.

Working Together for Patient Health Kay Ball, Ph.D., RN, CNOR, CMLSO, FAAN, a perioperative consultant and adjunct professor at Otterbein University in Westerville, Ohio, compares the teamwork required for a successful surgery to all the different parts of the body needing to work together for a healthy person. “If the central service department doesn’t work closely with surgery, then the surgical department won’t run well or be as productive,” Ball says. “And if sterilized instruments aren’t available, then surgeries can be delayed and even cancelled.” “These two departments must communicate regularly with each other so their actions will complement each other,” Ball adds. William Duffy, RN, MJ, CNOR, FAAN, is the director for the nursing and healthcare administration masters of science in nursing program at Loyola University of Chicago’s Marcella Niehoff School of Nursing. He uses a different analogy to explain. “When you look at the chessboard of a hospital’s operation, you have multiple teams/departments all trying to achieve their individual goals,” says Duffy. “Everybody is making moves to achieve their checkmate, if you will, and win the day.” Duffy says he used to talk with his team frequently about the idea of “coopetition.” “As departments, we are in competition with each other, but at the same time we are cooperating with each other to provide better patient care,” he says. “If you follow the coopetition mindset, you know that if you want someone from another department to help you, then you need to also help them,” Duffy adds. Carolyn Hooks, CSPM, sterile processing program manager at Children’s Hospital of The King’s Daughters in Norfolk, Virginia, takes things a step further. “I think the first question is why are we even considered different departments?” she asks. “I say this because both areas (sterile processing and the OR) are so interconnected.” WWW.ORTODAY.COM

April 2021 | OR TODAY

COVER STORY

KAY BALL

WILLIAM DUFFY

Hooks believes the OR culture is moving away from segregation by departments toward a single group of people with mutual respect and a mutual goal of patient safety. “It is imperative that those of us in SPD appreciate the urgency and stress that may be happening in the OR suite,” says Hooks. “The bottom line is that if you are engaged in the entire process and have a healthy respect for those who support you and those you support, you’ll be more useful as a perioperative staff member.” Duffy includes in-patient units among the list of departments where teamwork is essential. “As a perioperative director, I really worked to keep up my relationship with my inpatient counterparts,” he says. “I tried not to point fingers but instead to respect the challenges they faced in meeting their goals when it comes to preparing patients for surgery,” Duffy adds. “Kindness and support go a long way.”

Communication is Critical

CAROLYN HOOKS

LISA SPRUCE

MELANIE PERRY

OR TODAY | April 2021

Perhaps the most common cause of friction between departments is poor communication. “Good communication is a necessary component for good teamwork between surgeons and nurses,” says Melanie Perry, RN, BSN, CNOR, the host of First Case, a perioperative services podcast, and creator of The Circulating Life, a blog for OR nurses. She gives the example of surgeons clearly stating what will be needed for the surgery when posting a case. “This ensures that the perioperative staff is prepared and reduces delays and frustration,” she says. Perry tells the story of a recent rotator cuff procedure to illustrate the importance of good communication. “Nothing in the posting mentioned that it would be an arthroscopic case, and this particular surgeon routinely does open rotator cuff repairs, so we set up for an open case,” says Perry. “When the resident informed us that the case was supposed to be a scope,

we had to pull all new instruments, reposition the patient and gather new equipment, which of course delayed the case.” Hooks stresses the importance of simple planning when it comes to improving teamwork between the SPD and OR. “For example, when a procedure card is regularly updated, the SPD staff can properly prepare the surgical trays and case carts.” “Or when an SPD technician uses critical thinking and good communication skills while pulling cases to identify any needs or shortages prior to case time, this helps the surgery proceed more efficiently,” Hooks adds. Hooks says she has witnessed scenarios where proper planning didn’t take place, resulting in a pulled case or surgical tray being insufficient. “Inevitably, SPD staff are called into the OR as the sacrificial lamb,” she says. “This clearly is not the time for excuses or defensive behavior. We must take one for the team and then move forward to fix the situation.” About 70 percent of adverse events in the perioperative setting are caused by communication breakdowns among team members, according to Lisa Spruce, DNP, RN, ACNP, CNOR, CNS-CP, ACNS, FAAN, the director of evidence-based perioperative practice for the Association of periOperative Registered Nurses (AORN). “This is why it’s so important for all departments and teams to work well together and improve communication,” says Spruce. “Valuable information is shared between team members across many departments and this information is handed over to multiple personnel during the patient’s surgical encounter.” Spruce says she has seen the harm that can result when communication breaks down and a team member fails to speak up. “Most often, this is due to intimidating behaviors,” she says. “Team members are sometimes afraid to speak up when they experience intimidation or disrespectful and abusive behavior.” Health care facilities should promote respect among all personnel “by WWW.ORTODAY.COM

“ I tried not to point fingers but instead to respect the challenges they faced in meeting their goals when it comes to preparing patients for surgery. Kindness and support go a long way.” – William Duffy, RN, MJ, CNOR, FAAN

encouraging honesty, learning and collaboration and speaking up,” Spruce adds. “They should also hold personnel accountable for their behavior.”

Create a Blame-Free Environment A big part of improving communication is avoiding the “blame game.” “A blame-free environment must be created so that infractions can be quickly identified and handled,” says Ball. “If staff members feel that they would get into trouble by reporting problems, then problems will always be present.” Another part is assuming responsibility and accountability and not giving in to the temptation to point fingers. “I find it interesting how things work when everyone in the OR takes the blame as a whole,” says Hooks. “It’s pretty amazing – we just move on.” Hooks believes that one phrase in particular – “That’s not my job” – is especially counterproductive. “To me, this is profanity in the workplace,” she says. “And let’s not forget the dreaded information hoarders.” While surgeons sometimes have a reputation for treating other team members poorly, Perry says she has also witnessed nurses treating surgeons disrespectfully. “They dislike a particular surgeon for whatever reason so they’re rude, or they go slower during turnover, or they aren’t as quick to grab needed supplies as they would be for other surgeons. In the end, this keeps the case from going as smoothly as it could,” says Perry. “The lack of teamwork affects not just the surgeon, but the patient as well.” Another obstacle to teamwork that WWW.ORTODAY.COM

Duffy sees is the pressure that many health care leaders feel to meet productivity targets. “Productivity consumes many managers, and it drives their decision making,” says Duffy. “Their individual performance becomes more important than the organization’s overall performance.” What happens next, says Duffy, is that units start unilaterally deciding operational issues without thinking about the downstream or upstream impact. “When everybody is looking out to preserve their own jobs, the cooperation part of coopetition is lost,” he says. “I realize that meeting productivity targets and controlling labor expense and supply utilization are all important factors, especially for organizations with thin margins,” Duffy adds. “But no one is an island – especially in health care. Leaders who do not see the need to have relationships where you support others at times and then they support you only exacerbate team problems.”

Taking Concrete Steps Charlotte L. Guglielmi, MA, BSN, RN, CNOR, FAORN, the clinical manager for perioperative education at Beth Israel Deaconess Medical Center in Boston, says her facility took concrete steps to improve teamwork when they experienced a highly publicized wrong-site surgery back in 2008. “One of the first things we did was create a weekly safety huddle where chiefs of divisions and chairs meet to review all the debriefs,” she says. “We also started what we call Faculty Hour, a dedicated time during the workweek when multi-disciplinary teams come together to find solutions to common

problems.” “This presents an opportunity to address unusual things that come up that nobody seems to know how to tackle,” Guglielmi adds. Hooks says she has had many opportunities to see good teamwork in action. “One in particular was a project we worked on to right-size our surgical trays,” she says. “The ENT specialty staff and surgeons took the time to really dig in and make major changes, including downsizing trays and redeploying instruments. This has reduced re-work and saved money for the organization.” Spruce stresses the importance of establishing a team of stakeholders from all departments. “They should have the authority and responsibility to provide oversight for system design, implement team training, develop communication tools, review safety measures, identify patient safety issues and report data to the leadership team.” Personnel also need to collaborate and support each other “by crosschecking and monitoring so mistakes are captured,” Spruce adds. “And they should ask questions and request what is needed of each other, give timely and specific feedback to each other, and make sure they are verifying critical patient information by reading back what they have heard from their colleagues.” Guglielmi believes that the most important factor in improving teamwork is getting engagement from leadership at the C-suite level. “Teamwork has to be fostered at the top,” she says. “You need somebody who can go beyond clinical leadership to the senior management team. Otherwise, you’re never going to make it happen.” In the end, improving teamwork and working well together “ensures that we’re providing the best possible care to our patients,” says Perry. “It also lowers frustration levels, increases efficiency, reduces delays and improves the working environment for all of us.”

April 2021 | OR TODAY

SPOTLIGHT ON:

Lamont R. Jones, MD, MBA, FACS

Vice Chair, Department of Otolaryngology HNS at Henry Ford Hospital Director Cleft and Craniofacial Clinic

BY MATT SKOUFALOS

hen the novel coronavirus (COVID-19) pandemic hit Michigan in early 2020, the surgical suites at

Henry Ford Hospital – like those in every other such facility across much of the country – were closed to all non-emergency procedures by governmental order.

The news came after what Dr. Lamont Jones, vice chair of Henry Ford’s department of otolaryngology and director of its cleft and craniofacial clinic, described as a typically busy season for surgeries there. Although “things were humming along like normal,” Jones’ department had begun to work out contingency plans in case its ventilator inventory needed to be reallocated to COVID-19 patients. “We started getting our increased numbers, and it was obvious that we needed to make some adjustments to plan for our surge,” Jones said. After an order to cancel elective cases took effect, Jones’ department pivoted to telemedicine consultations and patient screening. A translational researcher as well as a clinician, Jones took a lot of work home with him, and began to carry on remotely. Meanwhile, at Henry Ford West Bloomfield Hospital, Zdenka Jonic, who manages environmental services (EVS) and patient transport, was making her own preparations for the impact of the 44 OR TODAY | March 2021

pandemic. As the 191-bed hospital began to swell with more patients, many of whom required isolated rooms, Jonic returned to work after a bout of the flu to discover a full facility. “It was new for everybody,” she said. “We were well prepared and didn’t really have to divert patients from coming here; it was the work of multiple teams together, but we had a really good plan.” Jones continued working from home, where his immediate family had all been taken ill with the virus. As they quarantined, he pressed on with research and departmental administrative work, and began to notice that, as “the work sort of switched for the health system” amid its pivot from procedural to inpatient care, it meant a lot more was being asked of Jonic and her EVS team. “It’s a process cleaning patient rooms – and I don’t think people realize how complex a process – of seeing patients, moving patients through the hospital, and repeating that process to allow for new patients to come through,” Jones said.

“On one of the [administrative] calls, it was mentioned that there was a lot of work for the environmental services department,” he said. “I thought it would be a simple and easy thing to do to volunteer, specifically at night and on the weekends, as a way of supplementing the traditional hours that the EVS was already doing. I wasn’t looking to draw a whole bunch of attention to myself.” With his family recuperating and his departmental goals temporarily realigned, Jones found himself in a position to help. Meanwhile, several members of Jonic’s team, who were unaccustomed to being the front-line workers they’d become, fell ill or needed to quarantine. At one point, her staff was reduced by half, while patient volumes remained high. “We were learning and getting new information every day,” she said. “It really fluctuated how we could operate.” Recognizing the increased demand for EVS, Jones reached out to his chief medical officer, expressing a willingness to help. Jonic got his note, and set Jones up with a WWW.ORTODAY.COM

The environmental services team at Henry Ford West Bloomfield Hospital, uses a UV robot when cleaning and sanitizing rooms. The team named their newest machine Lamont, in honor of Dr. Lamont Jones. In the spring when COVID-19 cases were at peak levels and elective surgeries were canceled, Jones decided to use his free time to help the department clean rooms.

Xenex ultraviolet light decontamination robot, with which he began disinfecting patient rooms. “It was a surprise that it came from one surgeon and the vice chair of a department, and then it made me feel really thankful and grateful that Dr. Jones recognized the need for our patients,” Jonic said. “That was another way of him doing the right thing for the patients; it also helped my department so that we could concentrate on different tasks while this very important step in providing a safe environment was completed.” “We work as a team to provide care for patients, and what it really showed is that everybody’s job is important,” Jones said. “Everybody has an opportunity to contribute, and that’s what we did for the health system.” Jones’ volunteerism proved contagious within his own department and the hospital itself. Other members of his department picked up emergency department shifts; some clinical staff were redeployed to help with EVS needs, and then, as the health system transitioned through the surge, other support staffers were reassigned, which helped limit surgical team furloughs. “A lot of departments were doing things that they weren’t accustomed to doing,” Jones said. “Most people were WWW.ORTODAY.COM

looking for ways to contribute. We’re used to being busy; sometimes when you’re sitting being idle, a lot of people are not used to doing that.” “It was very encouraging, the outpouring of support that we received,” he said. “I wasn’t surprised because I know the type of people we work with. People went over and beyond the call of duty to pitch in so that we could accomplish our numberone goal: to provide the best care that we could for patients in a rapidly changing environment.” The extra detail lasted almost two months, until the hospitals could return to normal operations. In that time, Jones and his colleagues covered about 100 EVS shifts. More than that, they gave their peers some critical support when it was most needed, and helped eliminate a bottleneck in patient throughput at a time when making more space for the next hospitalized person helped to save lives. “You could put a dollar amount to it, but it would not fully represent what

everybody was able to do cleaning the rooms,” Jones said. “This highlighted the wonderful work that EVS does on a daily basis, and that they don’t always get the recognition that they should. Those were the backdrops that made it easy for people to step up and assist.” “It meant a lot to me and my team to see that we are not left alone,” Jonic said. “Having that support from clinical staff, was very, very important.” “For a lot of us, this hopefully will be the most challenging period in our lifetimes,” Jones said. “And I think that, to look back, to know that everybody banded together and did whatever it took to rise to the occasion, will be a memory and a feeling that I’ll cherish.”

– Do you know a perioperative professional OR Today should feature in a Spotlight On article? Email your nomination to Editor@MDPublishing.com.

April 2021 | OR TODAY

OUT OF THE OR fitness

Necessary Body Weight Basics By Miguel J. Ortiz round this time last year just about the entire world was hit with COVID-19. In the U.S. everything was officially shut down around mid-March. In April a lot of people already had an idea about what to do for exercise – especially with everything closed. A lot of people’s circumstances varied, but one thing was certain – it was vital to become healthier as a society. And, for society to be healthier, we had to work on ourselves by changing our diet, exercising more or eliminating bad habits like smoking.

With all the gyms closed, many were forced to become innovative with their workouts. Some people had equipment dilemmas, for others it was a lack of motivation. A little over a year later, some places remain closed, but there is hope. We also have a lot more people dedicated to exercise, a society driven to become healthier and an online fitness industry that is booming. So, since health is wealth, let’s look at some bodyweight movements that are necessary for maintaining functional movement patterns. They will keep you ready to attack the day. First, I think it’s very important that we start on the floor and work our way up. Make sure you use a mat, carpet or something soft. Let’s begin with the fa-

OR TODAY | April 2021

mous glute raise. This exercise is not only a great glute activator, but it also assists in strengthening your core. Strengthening your core is crucial for posture and bigger movement patterns. A glute raise is performed by lying down on your back with your knees bent and your feet flat on the floor. Begin by pressing your heels into the floor and lifting your hips off ground. Make sure to squeeze your glutes on the way up for proper engagement and to ensure proper movement of the spine. For the second movement, we are still on the floor. The next movement is a kneeling bi-lateral raise. This exercise is excellent for balancing out the spine, engaging your core and stretching the shoulder blade. Start with hands and knees on the floor, you’ll begin by raising one leg back to the wall behind you, do not try to raise toward ceiling as we want to keep a neutral spine, no arching. If you raised you right leg try to raise your left arm (opposite) toward the wall in front of you. This will challenge your core strength and balance. For the third exercise, still on the floor, is the push up. If you have bad wrists or a bad back, you can start with some good planks. You can also do push-ups from your knees or on an elevated surface. Either way, these exercises focus more on core and upper body. However, there is a trick. To completely eliminate any pain in your back when doing push-ups, engage

your glutes before beginning the rep and it will do wonders. The fourth exercise, and now we can stand, are squats. Whether exercising or simply picking something up, our legs are crucial for movement and core strength. If you need assistance when preforming multiple reps, I suggest using a stable chair to repeatedly sit up and down. This way you can tell progress is being made when daily routines get easier. The fifth exercise is the hip hinge/toe touch. This movement focuses on utilizing the muscles in your legs, more specifically hamstrings and glutes, to align your back while hinging/bending over. This not only works the legs and hips more appropriately but strengthens the core as well. And, personally, I believe at any point in time someone should be able to touch their toes. It’s a simple test of flexibility and general mobility of lower and slightly upper body. Use these five exercises daily, performing at least two sets of 10 reps of each movement and your body will be sure to thank you down the road. 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

An Origami-inspired Medical Patch for Sealing Internal Injuries By Jennifer Chu any surgeries today are performed via minimally invasive procedures, in which a small incision is made, and miniature cameras and surgical tools are threaded through the body to remove tumors and repair damaged tissues and organs. The process results in less pain and shorter recovery times compared to open surgery.

While many procedures can be performed in this way, surgeons can face challenges at an important step in the process: the sealing of internal wounds and tears. Taking inspiration from origami, MIT engineers have now designed a medical patch that can be folded around minimally invasive surgical tools and delivered through airways, intestines and other narrow spaces to patch up internal injuries. The patch resembles a foldable, paper-like film when dry. Once it makes contact with wet tissues or organs, it transforms into a stretchy gel, similar to a contact lens, and can stick to an injured site. 48

OR TODAY | April 2021

In contrast to existing surgical adhesives, the team’s new tape is designed to resist contamination when exposed to bacteria and bodily fluids. Over time, the patch can safely biodegrade away. The team has published its results in the journal Advanced Materials. The researchers are working with clinicians and surgeons to optimize the design for surgical use, and they envision that the new bioadhesive could be delivered via minimally invasive surgical tools, operated by a surgeon either directly or remotely via a medical robot. “Minimally invasive surgery and robotic surgery are being increasingly adopted, as they decrease trauma and hasten recovery related to open surgery. However, the sealing of internal wounds is challenging in these surgeries,” says Xuanhe Zhao, professor of mechanical engineering and of civil and environmental engineering at MIT. “This patch technology spans many fields,” adds co-author Christoph Nabzdyk, a cardiac anesthesiologist and critical care

physician at the Mayo Clinic in Rochester, Minnesota. “This could be used to repair a perforation from a coloscopy, or seal solid organs or blood vessels after a trauma or elective surgical intervention. Instead of having to carry out a full open surgical approach, one could go from the inside to deliver a patch to seal a wound at least temporarily and maybe even long-term.” The study’s co-authors include lead authors Sarah Wu and Hyunwoo Yuk, and Jingjing Wu at MIT.

Layered protection The bioadhesives currently used in minimally invasive surgeries are available mostly as biodegradable liquids and glues that can be spread over damaged tissues. When these glues solidify, however, they can stiffen over the softer underlying surface, creating an imperfect seal. Blood and other biological fluids can also contaminate glues, preventing successful adhesion to the injured site. Glues can also wash away before an injury has fully healed, and, after application, they can also WWW.ORTODAY.COM

The new origami-inspired medical patch can be folded over tools like surgical staplers (shown here) and threaded through the body to suture tissues and organs. (Photo courtesy of the researchers) LEFT: MIT engineers have designed paper-like medical tapes that can fold around surgical tools and transform into soft, strong adhesives when pressed against tissues. (Photo: Felice Frankel)

cause inflammation and scar tissue formation. Given the limitations of current designs, the team aimed to engineer an alternative that would meet three functional requirements. It should be able to stick to the wet surface of an injured site, avoid binding to anything before reaching its destination, and once applied to an injured site resist bacterial contamination and excessive inflammation. The team’s design meets all three requirements, in the form of a three-layered patch. The middle layer is the main bioadhesive, made from a hydrogel material that is embedded with compounds called NHS esters. When in contact with a wet surface, the adhesive absorbs any surrounding water and becomes pliable and stretchy, molding to a tissue’s contours. Simultaneously, the esters in the adhesive form strong covalent bonds with compounds on the tissue surface, creating a tight seal between the two materials. The design of this middle layer is based on previous work in Zhao’s group. The team then sandwiched the adhesive with two layers, each with a different protective effect. The bottom layer is made from a material coated with silicone oil, which acts to temporarily lubricate the adhesive, preventing it WWW.ORTODAY.COM

from sticking to other surfaces as it travels through the body. When the adhesive reaches its destination and is pressed lightly against an injured tissue, the silicone oil is squeezed out, allowing the adhesive to bind to the tissue. The adhesive’s top layer consists of an elastomer film embedded with zwitterionic polymers, or molecular chains made from both positive and negative ions that act to attract any surrounding water molecules to the elastomer’s surface. In this way, the adhesive’s outward-facing layer forms a water-based skin, or barrier against bacteria and other contaminants. “In minimally invasive surgery, you don’t have the luxury of easily accessing a site to apply an adhesive,” Yuk says. “You really are battling a lot of random contaminants and body fluids on your way to your destination.”

Fit for robots In a series of demonstrations, the researchers showed that the new bioadhesive strongly adheres to animal tissue samples, even after being submerged in beakers of fluid, including blood, for long periods of time. They also used origami-inspired techniques to fold the adhesive around instruments commonly used in minimally invasive surgeries, such as a balloon catheter and

a surgical stapler. They threaded these tools through animal models of major airways and vessels, including the trachea, esophagus, aorta and intestines. By inflating the balloon catheter or applying light pressure to the stapler, they were able to stick the patch onto torn tissues and organs and found no signs of contamination on or near the patched-up site up to one month after its application. The researchers envision that the new bioadhesive could be manufactured in prefolded configurations that surgeons can easily fit around minimally invasive instruments as well as on tools that are currently being used in robotic surgery. They are seeking to collaborate with designers to integrate the bioadhesive into robotic surgery platforms. “We believe that the conceptual novelty in the form and function of this patch represents an exciting step toward overcoming translational barriers in robotic surgery and facilitating the wider clinical adoption of bioadhesive materials,” Wu says. This research was supported, in part, by the National Science Foundation. For more information, visit https://onlinelibrary.wiley.com/ doi/10.1002/adma.202007667

April 2021 | OR TODAY

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OUT OF THE OR EQ factor

Working With ‘Steady’ Styles By daniel bobinski, M.Ed. hree months ago, I started a series on identifying behavioral styles. Four core styles exist, and 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.

So far, we’ve covered the Dominant style – people who are more taskfocused and comfortable making high-risk decisions quickly. Then, we covered “Influencers,” who are comfortable making high-risk decisions quickly, but focusing more on people than tasks. In this installment we’ll cover the “Steady” style. Like Influencers, they focus on people, but “Steady” types prefer lower-risk decisions and taking their time when making those decisions. We call them Steady because a predominant characteristic is preferring a stable environment without a lot of change.

Value to the team Those with a strong “Steady” style are dependable team workers who work hard for a leader or a cause. They tend to be good listeners. Loyalty is important to them, so they usually create

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long-term relationships. Because of that loyalty, strong Steady styles often finish their tasks, even if it takes extra hours to do get them done.

Ideal environment and motivations Steady people enjoy stable and predictable environments, and they prefer work that has established standards. If change must occur, they prefer learning about those changes well in advance, and they want to know the reasons for those changes. Those with strong Steadiness traits usually enjoy being part of a small, productive team in which they can develop relationships. They are motivated by receiving words of specific encouragement, but they don’t usually like being center of attention.

Best communication methods Someone with a Steady style often blends personal and work topics into the same conversation, so it’s good to begin conversations with a personal comment. Something as simple as, “How are you doing?” is better than jumping headlong into a business discussion. When discussing future activities, draw out their thoughts and goals in a non-threatening, conversational manner. Avoid making demands or threating them with any position of power you may have. Steady styles dislike conflict, so it’s best to keep conversations low-key

and non-threatening. And, because of their dislike for conflict, they are unlikely to bring up any differences of opinion. That’s why it’s vital to watch their body language for any signs of disagreement. This can be difficult, as people with strong Steady styles tend to have a good poker face, so a good “best practice” when working with strong Steady styles is to ask if they have any concerns about ideas or plans being discussed. Perhaps the most important communication technique for Steady styles is giving them time to think. In other words, don’t force them to make quick decisions. Give them good information and then let them consider their options. In the next issue I’ll be reviewing the “Conscientious” 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.

April 2021 | OR TODAY

OUT OUTOF OFTHE THEOR OR recipe nutrition

Seafood: A Pandemic Change for the Better By KIRSTEN Serrano he pandemic has changed the way we eat, and some of those changes have been for the better. One notable change is that we are eating more seafood at home. In December 2020, fresh and frozen seafood sales were up about 25% from a year before.1 Before the pandemic, Americans ate seafood when dining out and rarely prepared it at home. An astonishing 70% of seafood was purchased from restaurants. When restaurants closed, seafood consumption bottomed out. As the pandemic wears on, more of us are including seafood in our cooking at home. Seafood consumption is still down overall, but we need to keep up our new seafood-at-home habit even when restaurants are fully open. The health benefits of seafood are too big to pass up.

Nutritionally, seafood is a powerhouse. Nutrient dense and easy to digest, seafood has more going for it than I can sum up in one column, so I am going to focus on one major 52

OR TODAY | April 2021

benefit. Let us take a look at how the fats in seafood affect our health.

Seafood is full of Omega 3 fats You have likely heard of Omega 6 and Omega 3 fatty acids. We need both, but we need them in a healthy ratio. An ideal fatty acid ratio of essential omega fatty acids 6:3 falls between 1:1-3:1. The estimate is that the standard American diet is about 15:1, but I have seen estimates that it is as high as 40:1. This imbalance is a national emergency. Looking at the chart on the following page, it is easy to think of Omega 6 as bad and Omega 3 as good, but that is an oversimplification. Inflammation, constriction and pain are important bodily functions. Problems ensue when the Omega 6:3 ratio is out of balance. Too much Omega 6 in the diet can contribute to cancer, heart disease, diabetes, obesity, mental disorders and more.2 If the pandemic has taught us anything, it is that we want to reduce inflammation and have a strong immune system. Increasing seafood in our diet goes a long way in correcting our Omega 6 to 3 ratio and sets us up for better physical and mental health.

Some of the richest sources of Omega 3 fats are salmon, anchovies, sardines, oysters, tuna, mackerel and squid. Salmon is so rich that it can have 100 times more Omega 3 fats than beef.3 I recommend eating seafood at least 4 times a week. The common hurdles to eating more seafood at home are price, knowledge about selecting/preparing it and availability. Here are some tips for overcoming these hurdles and harnessing the power of seafood: Price. Stock up on canned seafood. Nothing beats the convenience, shelf-stability and price point of canned fish. Canned seafood turns into easy meals. Tip: Only buy seafood packed in water or olive oil. Seed oils are high in Omega 6. Selection: Sustainability and quality matter. We need to eat more seafood and make sure it is around to eat in the future. Consult an online guide to seafood sustainability like Seafood Watch from the Monterey Bay Aquarium. Preparation: If cooking seafood is overwhelming, focus on getting good at one method. Seafood is very easily baked or broiled. The trick is that seafood cooks much more WWW.ORTODAY.COM

OUT OF THE OR

nutrition

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Omega 3 Fatty Acids

Inflammatory Constriction of blood vessels Cause pain Immune suppression

Anti-inflammatory Dilation of blood vessels Reduce pain Immune enhancing

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quickly than other meats so look up what temperature to cook it to and use a meat thermometer to check frequently. Availability: If your concern is about how fresh your seafood is, know that frozen is often the best option. A lot of seafood is flash frozen right on the boat at peak quality and is the better option. Fresh farmed options are often a great choice too. Farming operations vary in quality so refer to a guide like Seafood Watch to help. If you are not seeing the items you want at a local grocer (especially for those of us that are landlocked), shop online. Like everything else, buying seafood online is an ever-increasing option.

REFERENCES: Pomranz, Mike. “More Americans Appear to Be Cooking Seafood at Home due to the Pandemic.” Food & Wine, 25 Jan. 2021, www.foodandwine.com/news/americans-buying-more-seafood-pandemic. Accessed 6 Feb. 2021. 1

Robinson, Jo. “Eat Wild - Health Benefits.” Eat Wild, 2019, www. eatwild.com/healthbenefits.htm. Accessed 1 Jan. 2020. 2

McGee, Harold. “Grass-Fed Beef vs. Farmed Salmon.” Curious Cook, 6 Nov. 2006, www.curiouscook.com/site/2006/11/grass-fed-beef-vsfarmed-salmon.html#:~:text=The%20long%2Dchain%20omega%2D3s. Accessed 7 Feb. 2021. 3

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

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www.ORToday.com April 2021 | OR TODAY

OUT OF THE OR recipe

Cuban Chicken with Salsa Fresca INGREDIENTS: • 1 cup grapefruit juice

Recipe

• 2 tablespoons olive oil

the

• 2 teaspoons garlic powder • 2 teaspoons cumin • 2 teaspoons paprika • 1 teaspoon crushed red pepper • 1 1/4 pounds boneless, skinless chicken breasts Salsa Fresca: • 1 cup grapefruit segments • 1/2 jicama, cubed • 1/2 red onion, chopped • 3/4 cup grapefruit juice • 4 tablespoons olive oil • 1/2 cup fresh cilantro, chopped • 1 jalapeno pepper, chopped

By Family Features

OR TODAY | April 2021

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OUT OF THE OR recipe

A Fresh, Flavorful Take on Family Dinner By Family Features f your family ever gets stuck in a dinner routine rut, it can feel like you’re eating the same recipes over and over again.

However, this fresh and unique recipe for Cuban Chicken with Salsa Fresca might inspire you to think outside the culinary box and give your family members the satisfactory flavor they desire at dinnertime. With fresh ingredients and a wholesome flavor, this meal is perfect to add to your dinner menu rotation. The chicken is full of flavor and baked using multiple seasonings to create a Cuban-like taste. The salsa fresca, which is added on top of the chicken, is a tad sweet with grapefruit segments and juice, but also satisfying with jicama, onion, cilantro and jalapeno. It adds so much color to your plate, and all these flavors mash together for something unique and special.

Cuban Chicken with Salsa Fresca SERVES: 5 1. Heat oven to 400 F. 2. In large bowl, mix grapefruit juice, oil, garlic powder, cumin, paprika and red pepper until combined. Add chicken to bowl and turn to coat. Refrigerate 30 minutes or longer. 3. To make salsa fresca: In medium

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To start, create the marinade for your chicken and let it rest to allow all those wonderful spices to do their jobs. Set it in the fridge for 30 minutes or more. Next, it’s time to make the salsa fresca. Start by chopping red onion and jicama then add grapefruit and jalapeno to the mix. Add grapefruit juice, olive oil and, finally, cilantro. Stir well with a large spoon until everything is combined. Once the chicken is baked, cut it and assemble. The final result is a juicy chicken breast with a sweet yet crisp salsa topping. The flavors in this dish harmonize together to bring you a bite you have likely never experienced before. This meal is also nutritious with fresh fruit and lean chicken, so it’s a meal almost anyone can enjoy, even if you’re on a healthy eating kick. Find more recipes and family dinner ideas at Culinary.net.

bowl, mix grapefruit segments, jicama, red onion, grapefruit juice, olive oil, cilantro and jalapeno pepper until combined. Refrigerate until ready to serve. 4. Remove chicken from marinade. Place chicken in baking dish. Bake 25-30 minutes until chicken is cooked through. 5. Serve chicken with salsa fresca.

April 2021 | OR TODAY

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BRAND ADVOCATES ORGANIC HYDRATION DURING PANDEMIC

OAR Organic recently launched a consumer outreach and social media campaign that calls atten-

ROAR is unique to its category. In addition to being USDA Organic, it offers an array of in-demand attri-

tion to the importance of organic hydration in staying

butes – electrolytes, antioxidants, vitamins A, B3, B5,

healthy during these challenging times. In addition to

B6, C and E, no preservatives, and only two to three

reminding consumers to hydrate regularly and organi-

grams of sugar and 20 calories per serving.

cally, the campaign provides tips to stay safe, including

“All that goodness comes with great taste in four

flu shots, COVID-19 vaccination, wearing a mask and

delicious flavors: Mango Clementine, Cucumber Wa-

regular exercise to stay healthy and hydrated!

termelon, Blueberry Açaí, and Georgia Peach. ROAR is

“Of course, we want everyone to hydrate organically

available in an 18 oz. bottle and, at DrinkRoar.com, in

with ROAR, but more importantly, we want to do our

powder sticks. The 18-ounce bottle has SRP of $1.99 to

part to help everyone stay healthy and safe,” Alexan-

$2.49,” according to a press release.

dra Galindez, the president of ROAR, says. “Gaining

“We are really excited,” Galindez said. “A lot of

national distribution at 7-Eleven helps make the brand

people now have the opportunity to try ROAR for the

available to many more people. But our regional pres-

first time, and they’re going to be amazed by how good

ence at Wegman’s in the East and Albertson-Safeway in

it tastes. And when they read the label, by how good it

the West, and key natural retailers such as Fresh Mar-

is for them. ROAR is poised to become America’s go-to

ket, Fresh Thyme, King’s, Gelson’s, Bristol Farms, and

hydration beverage.”

Mother’s Market, and our e-commerce sales is critical to help people stay hydrated organically with ROAR.”

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For more information, visit www.RoarOrganic.com.

April 2021 | OR TODAY

INDEX

advertisers

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

Healthmark Industries Company, Inc.…………… 5

SIPS Consults………………………………………………………19

AIV Inc.……………………………………………………………… 25

Jac-Cell Medical……………………………………………… 50

Soma Technology……………………………………………… 11

AORN…………………………………………………………………IBC

Kapp Surgical Instrument Inc………………………… 23

Sympliant………………………………………………………………15

Calzuro.com……………………………………………………… 50

MD Technologies Inc.……………………………………… 27

TBJ Incorporated…………………………………………………31

CS Medical…………………………………………………………… 4

OR Today Webinar Series……………………………… 47

Cygnus Medical………………………………………………… BC

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

CATEGORICAL ANESTHESIA

Cygnus Medical………………………………………………… BC

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

Soma Technology……………………………………………… 11

Healthmark Industries Company, Inc.…………… 5

TBJ Incorporated…………………………………………………31

ASSOCIATION

MD Technologies Inc.……………………………………… 27

RESPIRATORY

AORN…………………………………………………………………IBC

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

Soma Technology……………………………………………… 11

C-ARM

SIPS Consults………………………………………………………19

SAFETY

Soma Technology……………………………………………… 11

TBJ Incorporated…………………………………………………31

Calzuro.com……………………………………………………… 50

CARDIAC PRODUCTS

INSTRUMENT STORAGE/TRANSPORT

Healthmark Industries Company, Inc.…………… 5

Kapp Surgical Instrument Inc………………………… 23

Cygnus Medical………………………………………………… BC

SINKS

CARTS/CABINETS

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

Cygnus Medical………………………………………………… BC

LAPAROSCOPY

TBJ Incorporated…………………………………………………31

Healthmark Industries Company, Inc.…………… 5

Jac-Cell Medical……………………………………………… 50

STERILIZATION

TBJ Incorporated…………………………………………………31

MONITORS

Cygnus Medical………………………………………………… BC

CS/SPD

Soma Technology……………………………………………… 11

Healthmark Industries Company, Inc.…………… 5

CS Medical…………………………………………………………… 4

ONLINE RESOURCE

MD Technologies Inc.……………………………………… 27

OR Today Webinar Series……………………………… 47

TBJ Incorporated…………………………………………………31

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

OR TABLES/BOOMS/ACCESSORIES

SURGICAL

DISINFECTION

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

MD Technologies Inc.……………………………………… 27

CS Medical…………………………………………………………… 4

Soma Technology……………………………………………… 11

SIPS Consults………………………………………………………19

Cygnus Medical………………………………………………… BC

OTHER

Soma Technology……………………………………………… 11

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

AIV Inc.……………………………………………………………… 25

SURGICAL INSTRUMENT/ACCESSORIES

ENDOSCOPY

PATIENT MONITORING

Cygnus Medical………………………………………………… BC

AIV Inc.……………………………………………………………… 25

Healthmark Industries Company, Inc.…………… 5

POSITIONING PRODUCTS

Kapp Surgical Instrument Inc………………………… 23

MD Technologies Inc.……………………………………… 27

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

TELEMETRY

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

Cygnus Medical………………………………………………… BC

AIV Inc.……………………………………………………………… 25

Sympliant………………………………………………………………15

Kapp Surgical Instrument Inc………………………… 23

TEST EQUIPMENT

FLUID MANAGEMENT

PRESSURE ULCER MANAGEMENT

Jac-Cell Medical……………………………………………… 50

MD Technologies Inc.……………………………………… 27

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

WASTE MANAGEMENT

FOOTWEAR

REPAIR SERVICES

MD Technologies Inc.……………………………………… 27

Calzuro.com……………………………………………………… 50

CS Medical…………………………………………………………… 4

TBJ Incorporated…………………………………………………31

GENERAL

Cygnus Medical………………………………………………… BC

AIV Inc.……………………………………………………………… 25

Soma Technology……………………………………………… 11

INFECTION CONTROL

REPROCESSING STATIONS

CS Medical…………………………………………………………… 4

MD Technologies Inc.……………………………………… 27

OR TODAY | April 2021

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