OR Today Magazine February 2022 by MD Publishing

Surgical Smoke

Smoke Evacuation

Pain Reduction Procedures

Lauren Nelson

TJC

MARKET ANALYSIS

CE ARTICLE

LIFE IN AND OUT OF THE OR

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OR TODAY | February 2022

contents

features

PUBLISHER

features

John M. Krieg

john@mdpublishing.com

VICE PRESIDENT

Kristin Leavoy

kristin@mdpublishing.com

SPOTLIGHT ON Laura Nelson

PATIENT PREP POWERS SUCCESSFUL SURGERIES

EDITOR John Wallace

editor@mdpublishing.com

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Taylor Powers Kameryn Johnson

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ACCOUNT EXECUTIVES Jayme McKelvey Megan Cabot

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OR TODAY CONTEST

Emily Hise

RECIPE OF THE MONTH

DIGITAL SERVICES Cindy Galindo Kennedy Krieg

EVENTS

INDUSTRY INSIGHTS

Kristin Leavoy

8 News & Notes 12 HSPA: Prioritize Departmental Errors to Prevent Future Mistakes 14 AAMI Roundup 16 TJC: Surgical Smoke Evacuator Maintenance Is Important 18 CCI: OEM (Online Enduring Materials) 20 OR Today Webinars: Webinar Addresses Principles of Reprocessing 22 Guide to AORN: AORN EXPO 2022: 3 Years in the Making

The global smoke evacuation systems

By applying evidence-based strategies,

Daniel Bobinski discusses how to “identify

market size is expected to reach $285.5

nurses can help reduce pain during minor

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million by 2028.

pediatric patient procedures.

start doing anything.”

MARKET ANALYSIS

CE ARTICLE

EQ FACTOR

26 M arket Analysis: Smoke Evacuation Systems Market On The Rise 27 Product Focus: Smoke Evacuation 30 CE Article: Reducing Pain During Minor Procedures for Pediatric Patients

OR Today (Vol. 22, Issue #2) February 2022 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.

54 Index

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. © 2022

OR TODAY | February 2022

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WEBINARS Jennifer Godwin

EDITORIAL BOARD Beyond Clean Vangie Dennis, MSN, RN, CNOR, CMLSO, Assistant Vice President, Perioperative Services with AnMed Health System

OUT OF THE OR

40 Spotlight On: Laura Nelson 42 Health 44 Fitness 45 EQ Factor 46 Nutrition 48 Recipe 50 Pinboard

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IN THE OR

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February 2022 | OR TODAY

INDUSTRY INSIGHTS

news & notes

OsteoCleanse Autograft Cleaning and Storage Total Knee Service Adds GPSReplacement Performed tracking Using Pixee Medical’s LifeNet Health, a leader in biologic surgical solutions, has Knee+ Augmentedadded real-time location-tracking technology to its OsteoCleanse autograft cleaning and storage service, bringing a Reality Platform new level of certainty to hospitals and patients. OsteoCleanse is a unique service, offered exclusively by LifeNet Health, to clean and store autograft bone for future implantation back into the patient. It is frequently utilized for patients who have undergone a decompressive craniectomy, where a portion of their skull has been removed to alleviate pressure on the brain. “It is vital to the patient’s recovery that these autografts are transported safely to and from LifeNet Health,” said Richard Rice, general manager of LifeNet Health Trauma and Craniomaxillofacial, “GPS tracking of each OsteoCleanse-prepared flap adds another layer of assurance to the patient and their surgeon that the flap is where they need it, when they need it.” A GPS device manufactured by Logistimatics is included in every OsteoCleanse shipment. This enables real-time tracking of the graft’s location from storage site to operating room. “OsteoCleanse’s system brings a level of certainty that traditional tracking methods like courier barcodes cannot provide,” said Daniel Osborne, vice president of global marketing and commercial strategy for LifeNet Health. “It allows us and our customers to be prepared for any contingency.” The introduction of GPS tracking to the OsteoCleanse process strengthens LifeNet Health’s position as the only full-service provider of this type of service – accounting for not only cleaning and storage, but also the logistics associated with autograft transport back to the patient.

OR TODAY | February 2022

MicroPort Orthopedics, a leader in orthopedic devices and technologies, has announced the successful completion of the first surgery in the U.S. utilizing Pixee Medical, an FDA-cleared augmented reality surgical application for assistance in total knee arthroplasties. The surgery was performed by Antonia F. Chen, MD, MBA, an orthopedic surgeon at Brigham and Women’s Hospital in Boston, using MicroPort Orthopedics Evolution Medial-Pivot Knee system, designed to deliver a high degree of stability and motion, leading to increased patient satisfaction and survivorship. In conjunction with Pixee’s Knee+ platform, the surgeon is able to achieve excellent precision and control, which may result in more efficiency in the operating room and a quicker return to full function for the patient. Pixee Medical’s Knee+ is a patented platform designed to assist orthopedic surgeons to perform surgeries better and faster by providing real-time positioning of instruments, right in their field of view via smartglasses. Knee+ is intuitive and requires minimal training since it does not change the overall technique for 90 percent of surgeons who use a conventional technique but have never utilized navigation or robots. “Our mission at MicroPort is to help the patient achieve full function, faster – and this ability to enhance precision and results during surgery will do just that,” said Benny Hagag, president of MicroPort Orthopedics. “The Pixee platform will be transformative in the continued efficiency and precision of our device systems.”

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Research Suggests PPE Does Not Eliminate Tissue, Blood and Fluid Exposure New published data suggest that personnel who process reusable medical instruments and equipment may be frequently exposed to tissue, blood, and patient fluids even when wearing recommended personal protective equipment (PPE). The findings, which appear in the American Journal of Infection Control (AJIC), the journal of the Association for Professionals in Infection Control and Epidemiology (APIC), detail the results of a pilot project evaluating splash generation during processing activities in equipment decontamination areas. The first real-world evaluation of PPE effectiveness for sterile processing personnel, the project found that PPE, even when properly donned and doffed, does not provide adequate protection from routine sterile processing activities. The authors highlight the need for more research to support evidence-based guidelines and instructions for safe processing. “This pilot documented substantial splashing and droplet dispersal during manual cleaning of medical instruments, and personnel got wet even though they were wearing all the recommended PPE,” said Cori L. Ofstead, president and CEO of Ofstead & Associates, and the paper’s lead author. “A combination of engineering solutions such as physical barriers and automated cleaning systems, better protective gear and splash/exposure-reducing practices is needed to reduce environmental contamination and personnel exposure in sterile processing and endoscopy departments.” To conduct their research, Ofstead and colleagues

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affixed moisture-detection paper to environmental surfaces and PPE in the sterile processing department (SPD) of a large, urban hospital. Highly trained, processing personnel then simulated performance of routine reprocessing tasks, including filling a sink, brushing a ureteroscope, and using a power sprayer when rinsing the sink basin. Following completion of the tasks, researchers detected splashes and droplet dispersal of at least three, and in some instances up to five, feet from the sink. This dispersal was associated with all but one of the simulated sterile processing activities. Additionally, currently recommended PPE did not adequately protect SPD personnel from exposure to water and cleaning solutions. The findings have implications for thousands of SPD personnel at hospitals, clinics and ambulatory surgery centers. “The results from this important real-world evaluation establish the need for additional research by auditors, regulators, and other decision makers to reassess the guidelines for personnel exposure and environmental contamination due to splashes generated in instrument processing areas,” said Ann Marie Pettis, BSN, RN, CIC, FAPIC, and APIC 2021 president. “Until then, controls such as splash-reduction training, correct donning and doffing of PPE, maintaining dirty-to-clean workflow, and cleaning and disinfecting workspaces between activities represent the best approach to reduce cross-contamination and protect sterile processing personnel from exposure to infectious pathogens.”

February 2022 | OR TODAY

INDUSTRY INSIGHTS

news & notes

Activ Surgical Wins ‘Inno on Fire Blazer’ Award BD Supports National Health Equity Project for Free Clinics BD (Becton, Dickinson and Company) has committed $500,000 to improve quality of care and reduce health inequities for patients served by free and charitable clinics across the United States. The New Jersey-based company will award $250,000 annually for the next two years to the health-focused relief organization Americares to support a multi-year project to collect demographic and patient health outcome data from free and charitable clinics nationwide. “We know that racial and ethnic groups in the United States experience worse health outcomes for certain conditions and are statistically more likely to face barriers that make it more difficult to access quality care,” said Tom Polen, chairman, CEO and president of BD. “Investing in the health of our communities is a pillar of the BD environmental, social and governance strategy. By supporting this important, first-of-its-kind initiative, we’re helping to empower U.S. free and charitable clinics to measure and track the degree to which their health care services are effectively addressing these inequities, and determine where additional support is needed to ensure more equitable health care quality and access for all.” Americares launched the Roadmap to Health Equity Initiative in 2017 in partnership with the National Association of Free and Charitable Clinics and Loyola University Chicago. The project is the first national effort to collect data measuring the quality of care provided by free and charitable clinics. “Achieving health equity – care that does not vary in quality because of someone’s race, gender, income, abilities, or location – requires a multi-faceted approach,” said Americares Vice President of U.S. Programs Edith Lee. “It requires the ability to collect and analyze data to determine if there are differing health outcomes for different groups. It requires a deeper learning and understanding of health equity and the factors that influence health outcomes. It

OR TODAY | February 2022

requires developing strategies and tools to address these factors that influence health outcomes. Thanks to the generous support of BD, we can continue and expand this ground-breaking effort.” Across the U.S., more than 2 million low-income, uninsured and underinsured patients rely on free and charitable clinics for their health care. Unlike federally funded clinics, free clinics often rely solely on volunteers and private donations to sustain operations. The clinics are a lifeline for individuals striving to support their families, including the undocumented or foreign-born adults who don’t qualify for government assistance and cannot afford health insurance. Without free and charitable clinics, many patients would utilize emergency rooms for basic health care needs or go without care. “The National Association of Free and Charitable Clinics was built on the fundamental premise that health care is a right and not a privilege. As an organization, we value human dignity, access to quality, compassionate health care and health equity,” said NAFC President and CEO Nicole Lamoureux. “We are grateful that BD has made such a strong commitment to the Roadmap to Health Equity Initiative, our clinics and our patients. The company’s support will allow dozens of more free clinics to participate in the project over the next two years.” The health equity project is part of Americares work supporting safety net clinics across the United States. Americares provides more than $200 million in medicine, supplies, education and training annually to a network of nearly 1,000 partner clinics nationwide. Americares U.S. Program helps partner clinics increase capacity, provide comprehensive care, improve health outcomes and reduce costs for patients. For more information, visit bd.com/en-us.

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Activ Surgical Inc. has been named the “Inno on Fire Blazer” in the Health and Medtech category as part of BostInno’s 2021 Inno on Fire Awards. The annual awards program recognizes top companies across eight categories and includes a ranking of the top 50 startups, people and nonprofit organizations (NPO) that are making impressive innovation strides in the Greater Boston region. Activ Surgical is a digital surgery imaging startup that is developing surgical intelligence hardware and software that exists within a class by itself. The company focuses on enhanced, real-time visualization capabilities for surgeons that combines advanced augmented reality (AR), artificial intelligence (AI) and machine learning (ML) technology. The company’s technology will enable surgeons to view critical physiological structures and functions, like blood flow, that cannot be seen with the naked eye while in the operating room. Activ Surgical’s goal is to empower surgeons’ decision making during a surgery to ultimately

enhance patient safety. “We want to congratulate this year’s Inno on Fire honoree companies and category-winning Blazers, including Activ Surgical,” said Carolyn Jones, market president and publisher of BostInno. “We also want to thank our staff and the venture investors and entrepreneurs in the community who helped us make this year’s selections.” “Activ Surgical has experienced tremendous growth and momentum in 2021, including the FDA clearance of our ActivSight interoperable imaging module, introduction of our ActivInsights software suite, a $45M Series B fundraise and the completion of our first in-human clinical trials,” said Todd Usen, chief executive officer, Activ Surgical. “This recognition from BostInno is validation of our team’s hard work, diligence and progress over the past 12 months. We are honored to be on this list that recognizes leaders in our home market.”

Ambu Awarded National Single-Use Endoscopy Contract with Vizient Ambu Inc. has been awarded a contract in the category of single-use visualization devices with Vizient Inc., the largest health care performance improvement company in the U.S. The agreement is effective Feb. 1, 2022. The contract with Vizient – whose members represent more than half of the hospitals and health systems in the U.S and serve 97 percent of all the academic medical centers – will further accelerate Ambu’s rapidly expanding share of the single-use endoscope market by offering Vizient members pre-negotiated pricing and terms for Ambu’s full suite of single-use products in bronchoscopy, urology, ENT and GI. This agreement also includes access to all new single use endoscopy launches. The creation by GPOs of specific single-use endoscope categories comes as the transition to single-use endoscopy

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continues to accelerate, with an eye on expanding hospitals’ capacity and avoiding costly and unnecessary expenses associated with workflow management and patient crosscontamination. “Our vision at Ambu is to be the most innovative singleuse endoscopy company and this agreement with Vizient enables us to better serve its member health systems, hospitals, and health care providers across the U.S.,” said Juan Jose Gonzalez, CEO of Ambu A/S. “We consider Vizient an exceptional company and are excited to work closely with its member organizations. Our portfolio breadth, innovation ecosystem and attractive economics mean we can be the partner of choice for health systems in their efforts to prevent device-related infections, boost health care economics and improve clinical workflows.”

February 2022 | OR TODAY

INDUSTRY INSIGHTS

IAHCSMM HSPA

Prioritize Departmental Errors to Prevent Future Mistakes By TONY THURMOND, CRCST, CIS, CHL, FCS hen errors in sterile processing (SP) occur, the department’s leader and team members must fully explore the reasons behind those incidents and promptly seek effective solutions – and they shouldn’t wait, either. The sooner errors are addressed and mitigated, the better the outcomes for health care customers and patients.

It’s important for SP professionals to recognize that all errors present opportunities for positive change; however, in order for that to happen, facilities must adopt a proactive rather than reactive approach. Reactive strategies can often be “Band-Aid fixes” that typically fail to allow positive opportunities for change. A proactive approach, on the other hand, allows better foresight into the error, with anticipation of removing future barriers. In the SP environment (and virtually all other health care departments), errors do occur, and it is never fun when they do. Changing how errors are approached and exploring opportunities to understand their full impact and reduce future errors is essential. Put simply, we must look at the attitude toward mistakes, the barriers that 12

OR TODAY | February 2022

allow for errors to occur, the reaction to our errors, and the best solutions for eliminating and preventing them in the future. What follows are four key factors that SP leaders and technicians must consider: ATTITUDE: If individuals do not grasp an error’s impact, they will never have the insight to make corrections. As a manager, it is challenging for me when an employee has the wrong attitude or approach to an error. I once had an employee tell me, “We should be able to make three or four mistakes a month” (obviously unacceptable). That same employee also tried to convince me that a mistake should only count when it is found in the operating room (OR) or other patient care area. Certainly, this sort of reasoning failed to keep the patient and our quest for quality at the forefront. Conversely, I have had employees who wanted to dig deeper to understand how an error occurred and how they could prevent future incidents. As a manager, I have taken a technician to the OR to discuss an error with the surgical team. We have all gotten those calls from surgeons who want us in the room immediately because they want to vent their frustrations about the error and hear how we plan on preventing another error from happening

in the future. Seeing our sincerity in handling the issues goes a long way. Taking a technician into the room to observe that interaction is beneficial, so the technician sees the error’s full impact. They can then share with their co-workers what they learned and explain how they saw the patient who was (or might have been) impacted by the error. Visualization is an especially effective training tool. BARRIERS: SP professionals must demand that they have what is needed to make them (and their teammates) successful in their given tasks (across all areas of the department). Barriers such as improper or inadequate cleaning equipment or tools in the decontamination create opportunities for shortcuts and oversights. Other barriers might include inadequate training or a lack of training materials for each technician. Each department should have a copy on file of the most current standards and guidelines, as well as all current manufacturers’ instructions for use for the items being handled/ managed by the department (this also includes operating manuals for the equipment in use in the department). Education must be provided to each technician within the department, and it should be developed for department-specific work. Ongoing WWW.ORTODAY.COM

reviews of the processes in place (and new processes as added) should be performed, along with a return demonstration to ensure each technician understands the task and how it should be performed. Daily huddles are also effective for communicating the day’s events and expectations for the next day, and for discussing any error that may have occurred (and any customer concerns or complaints). REACTIONS: Taking ownership of an error when it occurs isn’t always easy, but it is critical to success. The key to admitting mistakes is to learn from them, correct them and move on. Sincere apologies and the effort to admit the error and make necessary improvements are the best approaches for all involved. SOLUTIONS: Being proactive is the best measure for reducing errors. Solutioning a problem involves the following critical steps: 1. Continuous review of the needs of

the department. Seek opportunities to improve the safety for each worker. Proper personal protective equipment, tools, cleaning agents, equipment, training, etc., all will create a better working environment for staff. 2. Continuous review of the policies and procedures of the department to give staff the best processes and direction for handling issues. 3. Continuous monitoring of your instrument tracking system for recipe improvements, as well as reviews with the staff on sterilization monitoring and documentation. Last but certainly not least, human factors, which are ever-present, should be strongly considered whenever errors occur. Many managers struggle to determine the appropriate actions when a technician makes an error. I personally strive to look at each situation and then look for the barrier

that may have contributed to the error. I try to let each technician know about the error made and then determine whether they are experiencing any challenges. During these conversations, managers will hope for technicians who are responsive to the discussion or situation and then be willing to find solutions to reduce risks for a recurrence. During these discussions, I’ve found it helpful to educate and show empathy while pushing the ever-important message that the patient could have been impacted by the error. – Tony Thurmond, CRCST, CIS, CHL, FCS, serves as central service manager for Dayton Children’s Hospital. He is also a past-president, fellow and columnist for the Healthcare Sterile Processing Association (formerly known as the International Association of Healthcare Central Service Materiel Management).

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February 2022 | OR TODAY

INDUSTRY INSIGHTS

AAMI

AAMI Roundup he following is recent information from the Association for the Advancement of Medical Instrumentation (AAMI) that we think will be of interest to the readers of OR Today magazine.

What’s Left Behind: Assessing Residuals from Medical Device Cleaning It has long been understood that the manufacturers of cleaning formulations are responsible for demonstrating the inherent risks that come with the intended use of their product. However, according to a team of concerned scientists, lab operations managers, and microbiological quality and sterility assurance specialists, there are no regulations that specify how manufacturers can help users determine the risk of residual chemicals on device surfaces after cleaning. That’s why the team, hailing from Johnson & Johnson and Nelson Laboratories, recently published a study investigating the impact residual detergent chemistry can have on patient safety. The study “Assessing Detergent Residuals for Reusable Device Cleaning Validations” was published in BI&T, the peer-reviewed journal of AAMI. The researchers conducted cytotoxicity tests – measuring to what degree 14

OR TODAY | February 2022

a substance can damage a biological cell – in accordance with AAMI TIR30:2011(R)2016 and ISO 109935:2009, the established state-of-theart test for reusable medical device processing. Eight detergents for the cleaning of reusable medical devices were evaluated at 10 different concentrations. “The cytotoxicity profiles described in this study were clearly tested under worst-case conditions … assuming the lack of any rinsing during use,” the authors wrote. It was surprising to note then, that many these products “did not show considerable cytotoxicity” at recommended concentrations. This is startling, because the products are designed to break down biological matter, such as proteins and lipids, so that it can wash away. Only two of the detergents, Enzymatic C and D, posed a cytotoxicity threat all the way down to 0.2% of the maximum recommended concentration, implying that devices cleaned with these formulations will need to be thoroughly rinsed. What could confuse some users is that, in inspecting a manufacturer’s safety data sheet (SDS) alone, the formulation of enzymatic C will appear remarkably similar to enzymatic B. Enzymatic B proved safe even at 6% concentration – which is well above the residual

concentration that is expected after a rinsing (0.1-1%). “Because cleaning solutions consist of a combination of various chemicals … it is not practical to assume that the chemistry reported in the detergent manufacturer’s SDS is sufficient to accurately predict its toxicity profile,” the authors concluded. They are now calling for manufacturers to better define cleaning chemical performance “to allow for harmonization of safety and efficacy expectations.”

Seeking Harmony in Microbiological Quality Definitions A team of sterility assurance professionals has released a comprehensive glossary that proposes harmonized terminology commonly used in the design, control, and regulation of microbiologically controlled devices and drugs, such as those used in the clinical setting. The commentary, “Words Matter: A Commentary and Glossary of Definitions for Microbiological Quality,” helps establish a common lexicon that the authors say will better address challenges associated with “global economic, distribution, and regulatory requirements that are often confounding and evolving.” The article was published in BI&T, WWW.ORTODAY.COM

the peer-reviewed journal of AAMI. The glossary uses established definitions for commonly used terms when possible. However, the committee behind the document is proposing that, in specific cases, established definitions may need to be retired or revised if found to be too limited or redundant for modern use. The team, consisting of professionals from microbiology, sterility assurance, regulatory affairs, engineering, medical device design, pharmaceuticals, and the clinical setting, focused on definitions that are inherently simple and internationally relevant. As such, their proposed definitions avoid phrases or terms that would have an alternative meaning outside of English-speaking countries. To avoid common points of debate between manufacturers, regulators, and scientists, the definitions also prioritize scientific accuracy and “should not be open to individual interpretation.” The term biofilm, for instance, is a term that is often used incorrectly. This is in-part because scientific knowledge of biofilms has evolved, revealing that biofilms are not restricted to water systems. However, common definitions often continue to perpetuate this limitation, the committee claims. “A simpler definition in this glossary defines a biofilm as a community of microorganisms,” the authors wrote. The definition’s accompanying commentary delves deeper into describing wet and dry biofilms as well as a detailed description of what to look for when identifying a biofilm structure. More than 100 terms, ranging from “action level” to ”z value,” are defined in the glossary. The proposed definitions are supported by commentary from the authors and more than two dozen citations of peer-reviewed research. The glossary was written by Gerald McDonnel, BSc, Ph.D., senior director in microbiological quality and sterility assurance at Johnson & Johnson; Hal Baseman COO and principal at ValSource Inc; and Lena CordieBancroft, the president of Qualities Professional Services LLC. The glossary was designed with the knowledge of the members of the Kilmer Regulatory Innovation Team – borne of the revived Kilmer conferences for sterility assurance professionals – and dedicated to creating opportunities for cooperation and innovation between regulators and medical device manufacturers. WWW.ORTODAY.COM

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February 2022 | OR TODAY

INDUSTRY INSIGHTS

Joint Comission

Surgical Smoke Evacuator Maintenance Is Important By Herman A. McKenzie

In fact, whenever and wherever lasers, electrosurgical systems, radio frequency devices, hyfrecators, ultrasonic scalpels, power tools and other heat destructive devices are used, everyone in the area – including the patient – may be exposed 16

OR TODAY | February 2022

to surgical smoke. Surgical smoke plumes can contain toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde, bioaerosols, dead and live cellular material (including blood fragments) and viruses Over time, I realized there was a tie to physical environment compliance and the need to maintain medical equipment under the medical equipment standards: EC 02.04.01 and EC 02.04.03. As a matter of fact, use of smoke evacuators is tied to The Joint Commission’s element of performance for managing hazardous materials and waste: Standard EC 02.0.201 EP 9 states: “The organization minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous gases and vapors.”(Hazardous gases and vapors include, but are not limited to, ethylene oxide and nitrous oxide gases; vapors generated by glutaraldehyde; cauterizing equipment, such as lasers; waste anesthetic gas disposal (WAGD); and laboratory rooftop exhaust. (For full text, refer to NFPA 99-2012: 9.3.8; 9.3.9) While exposure of surgical smoke to patients is short-term and

relatively low risk, surgeons, perioperative nurses and other operating room staff are exposed to surgical smoke daily. At high concentrations, surgical smoke may cause ocular and upper respiratory tract irritation and potentially create visual problems for the surgeon. Therefore, it is so important for ambulatory surgery centers to be aware of the risks of surgical smoke and how they can best mitigate those risks. A recent Quick Safety advisory from The Joint Commission, “Alleviating the dangers of surgical smoke,” reviews current regulations, recommendations and standards on surgical smoke or lasers from several governmental and professional organizations, including from the Occupational Safety and Health Administration (OSHA), National Institute of Occupational Safety and Health (NIOSH), American National Standards Institute (ANSI), Association of periOperative Registered Nurses (AORN) and ECRI. The advisory also includes several safety actions for health care organizations that conduct surgery and other procedures using lasers and other devices that produce surgical smoke. Recommended safety actions

• Providing surgical team members with initial and ongoing education and competency verification on surgical smoke safety, including the organization’s policies and procedures. • Conducting periodic training exercises to assess surgical smoke precautions and consistent evacuation for the surgical suite and procedural area. Additional resources from The Joint Commission are provided in the advisory, along with resources from the Centers for Disease Control and Prevention (CDC), ANSI, AORN and several other academic journals. – Herman A. McKenzie, MBA, CHSP, is the director, engineering, standards interpretation group at The Joint Commission.

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February 2022 | OR TODAY

ooking back on my career as a biomedical engineering technologist prior to my position at The Joint Commission, I recall that one of my responsibilities included preparing purchase bid documentation for all new medical equipment in my hospital. I distinctly remember making sure that only highquality devices were considered and purchased for use in our operating rooms. Today, I more greatly appreciate the quality of the high-capacity dependable smoke evacuators, as smoke plume hazards are more closely studied. Back in the day, smoke plumes seemed, at minimum, unpleasant for clinical staff, but today we are learning more about the potential harm they cause.

to protect patients and health care workers include: • Implementing standard procedures for the removal of surgical smoke and plume through the use of engineering controls, such as smoke evacuators and high filtration masks. • During laser procedures, using standard precautions to prevent exposure to the aerosolized blood, blood by-products and pathogens contained in surgical smoke plumes. • Establishing and periodically reviewing policies and procedures for surgical smoke safety and control – making these policies and procedures available to staff in all areas where surgical smoke is generated.

INDUSTRY INSIGHTS

CCI

news & notes CCI

is a catalyst and integral partner.” (2021b). CCI believes that OEM is a tangible and substantive example of that partnership. In 2022, we will continue to add OEM to the CCI website while we also administer six credentials for the perioperative nursing community.

REFERENCES ANA Enterprise (n.d.) Nursing Continuing Professional Development. Accessed 21 November 2021 at: https://www.nursingworld.org/organizational-programs/accreditation/ncpd/#:~:text=The%20ANCC%20 Accreditation%20Program%20identifies%20organizations%20 worldwide%20that,implement%20and%20evaluate%20the%20highest%20quality%20NCPD%20activities.

OEM (Online Enduring Materials)

– James X. Stobinski, Ph.D., RN, CNOR, CNAMB, CSSM(E), is CEO of the Competency and Credentialing Institute.

Prevention (PIP) in Intraoperative Care Microcredential. Accessed 21 November 2021 at: Product Detail (cc-institute.org)

By James X. Stobinski n early November of 2021 I was invited by my colleague, Marianne Horahan, the director of certification services with the American Nurses Credentialing Center (ANCC) to speak at the ANCC National Magnet Conference. This was quite an honor. I co-presented with Marianne on the role of nursing specialty certification in the continuous professional development of nurses. Our theme was the potential value for nurses from voluntary nursing specialty certification programs.

The recertification processes of voluntary credentialing programs offer structured engagement throughout a career. Certification providers, such as the Competency and Credentialing Institute (CCI), can provide value to nurses with resources that otherwise might not be as widely available. Recertification programs, secondary to recently strengthened accreditation requirements, are shifting away from models based on the very familiar continuing education (CE) credits used for many years for licensure renewal. A gradual transition is underway with an emphasis on the continuous professional development (CPD) model. The CPD model is focused on learning outcomes versus time or hours-based 18

OR TODAY | February 2022

programs. The ANCC accreditation program for nursing CPD (ANA Enterprise, n.d.) is illustrative of reinforcing a professional development focus. The ANCC CPD accreditation program assures the highest caliber education to meet licensure or recertification requirements. A recent article by Reivent Technologies (2021) is germane to this transition away from a pure CE model by the certifying bodies. These authors state that, “61% of health care professionals find it difficult to attend meetings.” Attending professional meetings and workshops, which are a mainstay of CE-based systems, in addition to requiring a time and resource commitment can involve hassles – especially during a pandemic. The writers for Reivent make a case for online enduring materials (OEM) to address the CPD needs of health care professionals. The CE delivered at meetings and workshops is inherently ephemeral whereas OEM, as a collection of learning activities and materials, has more permanence and is often hosted on a website. Learners desire a one-platform solution where they can access learning activities and materials on one site, complete those activities and have the documentation of completion stored at that site for easy retrieval. The CCI offers OEM to certificants as a benefit of certification; many of

these materials are available without charges or fees. In addition, documentation of these activities populates recertification records in the registration system of the certificant. Any nurse holding an active CCI certification may access a diversity of CPD materials through the CCI Learning Management System (LMS). An example of an OEM is the Pressure Injury Prevention Microcredential recently developed in partnership with Mölnlycke Health Care AB. (CCI, 2021a). With the transition away from a solely CE-based system, CCI has concentrated a wealth of enduring professional development material within its proprietary LMS. Like the Mölnlycke microcredential, some of these materials were sponsored by corporate partners such as Beyond Clean and the National Institute of First Assisting (NIFA). In the LMS, using OEM, learners manage their own learning experience which allows them to tailor their professional development choices. The LMS is available 24 hours a day giving the learner immense flexibility at a low cost. The mission of the Competency and Credentialing Institute is, “To promote continuous professional development which drives safe, quality patient care.” Our vision is, “To grow a community of certificants and lifelong learners for whom CCI WWW.ORTODAY.COM

Competency and Credentialing Institute (2021a). Pressure Injury

Competency and Credentialing Institute (2021b). About us. Accessed 21 November 2021 at: About Us | Perioperative Certification | CCI (ccinstitute.org) Reivent Technologies (2021) [blog post]. Is “Learning Time” a Precious Commodity in Continuing Education? Accessed 7 November 2021 at: https://rievent.com/insights/blog/is-learning-time-a-precious-commodity-in-continuing-education

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February 2022 | OR TODAY

INDUSTRY INSIGHTS

WEBINAR SERIES

webinars

ONE CLICK.

EARN CEs.

Webinar Addresses Principles of Reprocessing

When you join us for a FREE webinar.

WEBINAR SERIES

Staff report he OR Today webinar “Understanding the Principles of Reprocessing” was sponsored by Advanced Sterilization Products (ASP) and eligible for 1 CE credit. OR Today is approved and licensed to be a Continuing Education Provider with the California Board of Registered Nurses, License #16623.

In this 60-minute webinar, ASP Senior Clinical Education Consultant Nancy Fellows discussed best practices aligned with terminal sterilization of surgical and medical instrumentation, reviewed the current and existing position of Spaulding classification and identified current sterilization modalities available in the health care environment. The webinar recorded 368 registrations with 165 health care professionals attending the live presentation. A recording of the webinar is available for on-demand viewing at ORTodayWebinars.live. After her presentations, Fellows took questions during a live question-andanswer session. The result was additional expert insights that webinar attendees can take to their workplace and implement proven practices. One question was, “What is the difference between a biological indicator (BI) and process challenge device (PCD)?” 20

OR TODAY | February 2022

THURSDAYS AT 2PM ET Fellows said that a biological is probably the most important sterilization monitor used for sterilization today. She then expanded on her answer. “BI’s are the only sterilization monitoring device that provides a direct measure of lethality or killing of spores or other micro-organisms during the process,” Fellows said. “AAMI’s Standard 79.” She explained that AAMI is the Association for the Advancement of Medical Instrumentation. “AAMI Standard 79 which is associated with steam sterilization, indicates a BI should be used with a PCD for routine sterilizer efficacy monitoring at least once a week, but preferably daily. So, they speak to steam sterilization and preferably stands out. But a process challenged devised or PCD contains a BI and a chemical indicator incorporated into a challenged presentation,” Fellows added. “A PCD is used to assess the effective performance of the sterilization process by providing a challenge to the process that is equal or greater than the challenge posed by the most difficult item in the load. And, I know I mentioned in the presentation, that is particularly important because not all loads that we run in our departments are the same over and over again.” “Some cycles have light instrumentation, and others may be heavier in the chamber. Some items are just as simple, a non-critical device, where others are

delicate and complicated,” she continued. “But AAMI Standard 58 states a PCD, should be used daily, but preferably in every sterilization cycle.” Fellows also answered questions about the Spaulding classification, HLD and more. Attendees provided positive feedback regarding the webinar in a survey that also asked for feedback regarding the 2021 OR Today webinar series. All of the 2021 webvinars are available for on-demand viewing at ORTodaywebinars.live. Several attendees praised OR Today and the webinar series. “The webinars from OR Today are extremely timely and valuable in today’s health care environment,” Infection Preventionist B. Walters said. “Excellent presentation of the various methods of sterilization and how they should be used. Would be excellent information and review for anyone working in OR or the reprocessing area,” Outpatient Surgery OR Unit Coordinator G. Lowrance said. “This webinar on the principles of reprocessing was presented in an interesting and informative format that included a plethora of valuable information relevant to the principles involved with reprocessing reusable patient devices,” said RMD Coordinator B. Bedingfield, RN. For more information, visit ORTodayWebinars.live.

WWW.ORTODAY.COM

ORTODAYWEBINARS.LIVE WEBINAR ARCHIVES ONLINE OR Today has been approved and is licensed to be a Continuing Education Provider with the California Board of Registered Nurses, License #16623. CBSPD CE credits when applicable.

INDUSTRY INSIGHTS

news &AORN notes

news & notes AORN

AORN EXPO 2022: 3 Years in the Making

The AORN Global Surgical Conference and Expo provides education, networking and hands-on learning.

Staff report

Daytime is for Learning hen AORN faced the difficult

W decision to cancel its Global

Surgical Conference & Expo not once, but twice in two consecutive years, the association had two primary concerns. The first was how it might deliver its session content and accompanying credit hours to the thousands of perioperative nurses who depend on the conference for their continuing education. And the second was how to connect the nurses to medical device representatives in a way that would help them learn about product advancements for the operating room and improvements for safe patient care. 22

OR TODAY | February 2022

“In the OR, nurses need to be flexible, resilient and able to quickly pivot when an unexpected surgical challenge occurs,” said AORN CEO/ Executive Director Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN. “We approached repurposing expo with that same mindset. In weeks, we took the entire five-day conference from a face-to-face event to an online presentation.” Groah said the event had a high online turnout and more credit hours were earned than in previous live events. The online conferences in 2020 and 2021 were also presented in a manner that provided industry sponsors with live meeting rooms where the nurses could connect with medical device represen-

tatives one on one. “But it’s the bonding from networking that the nurses have really missed,” said AORN President Holly Ervine, MSN, RN, NPD-BC, CNOR. “The pandemic risked the safety of our nurses and cancellation was necessary. But, even more concerning, we lost our ability to connect and share experiences with our colleagues from around the world.” The pandemic, says Ervine, has challenged nurses’ spirits. “We’re tired in a way we have never experienced, so this next expo has special events and sessions that will recharge our passion and help us reconnect with each other as well as our profession,” she said.

WWW.ORTODAY.COM

AORN’s Expo is the largest perioperative nursing conference in the world and, according to organizers, this year’s event in New Orleans, March 19-23, is expected to draw a large and especially enthusiastic crowd after the pandemic-imposed hiatus. This nursing conference is unique in that it is developed by perioperative nurses for perioperative nurses. The educational content in large part is based on the Guidelines for Perioperative Practice, the resource perioperative nurses refer to as the “gold standard” for safe care of the surgical patient and worker protection. The lead authors of the guidelines are AORN nursing staff. They will be presenting sessions on new recommendations for safe perioperative practice including covering some WWW.ORTODAY.COM

dramatic changes in the latest revision to the Guideline for Unintentionally Retained Surgical Items. The association continually revises guidelines to reflect new research findings, with recommendations that impact day-to-day practice. Expo provides the opportunity for attendees to hear directly from the experts what is different within the guidelines, and why changes were made. Over five days, in 12 specialty break-out tracks including infection prevention and control, sterile processing, informatics, and ambulatory surgery, attendees can earn as many as 200 credit hours. Topics will range from “Implementing Enhanced Recovery After Surgery Protocols for Total Joint Procedures in the ASC” to “Nurse Mentoring: Key to Meaningful Professional Integration

and Sustainable Future,” and “Code Black: When Stress Hijacks Your Brain in the OR.” AORN’s Leadership Summit, March 19-22, is sometimes referred to as a conference within the conference. Its sessions are developed for perioperative nurse executives and emerging leaders who seek to build or strengthen their leadership skills including understanding strategies for sound financial management, team mentorship and business plan development among other leaderfocused education. The Leadership Summit and Expo include presentations from several motivational speakers who, Ervine says, will help energize the nurses and herself. “We get caught up in what’s wrong with our shift, or our day, or myriad other distractions,

February 2022 | OR TODAY

INDUSTRY INSIGHTS

news &AORN notes

news & notes AORN

and we lose focus on what’s actually going well,” she said. “A push toward positivity can make an incredible difference in our perspective.” Expo is also a draw for nursing students who, with a student ID, receive a complimentary registration and AORN Student Membership in the association.

Advancements in the Operating Suite Perioperative nurses are key influencers when surgical teams determine which products and equipment will be purchased for the surgical services department. AORN is one of the few conferences that schedules exhibit hours around the education sessions to give exhibitors and nurses time to meet. As such, AORN’s Expo Hall, which is open March 20-22, is one of the largest surgical products trade shows in the U.S., attracting hundreds of leading medical companies and their representatives. The trade show floor dedicates 400,000 square feet to a presentation of the newest devices, equipment and resources that put technology, efficiency and safety options in front of the attendees. With support from Pfiedler Education, a division of AORN, many of the exhibitors will develop and present education workshops and hands-on simulation trainings with credit hours.

Nighttime is for Socializing “New Orleans is a perfect backdrop to welcome back the perioperative nurses,” said Groah. “And we are taking full advantage of the city’s culture, entertainment and incredible restaurants in our event planning.” Surgical nurses like a good party and each night in New Orleans will present a unique event, she says. “Our annual AORN Foundation party on Monday night is always popular. There are no wallflowers, it’s high energy and everyone dances.” This year’s AORN Foundation party is themed “Night of Stars” and, if the past is an indication, many of the nurses, along with their friends and family who also attend, will wear theme related outfits. “I expect to see lots of glam and glitter, stars on clothing, jewelry and even hats. We’ll see a lot of creativity.” This year AORN will also host Premier and Finale parties Saturday and Tuesday evenings. “We want to make sure attendees have a chance to meet old and new friends on day one so they can maximize their networking for the rest of the conference,” Groah adds. “And the Finale is a great cap to this celebration of finally being together again as perioperative professionals.”

DON’T MISS

THESE EXHIBITORS BD

i.c. medical

Booth: 6313

Booth: 6623

BD is one of the largest global medical technology companies in the world and is advancing the world of health by improving medical discovery, diagnostics and the delivery of care. www.bd.com

C CHANGE SURGICAL Booth: 7829

SurgiSLUSH™ Works for You. As your staff gets things done, SurgiSLUSH™ programmable freezers automatically produce & maintain optimal sterile slush inside sealed and protected containers. Confirmed Sterility. Increased Utility. Smarter Use. Compare! www.cchangesurgical.com

Healthmark Industries Booth: 7929

Healthmark offers infection control solutions and tools to manage the proper reprocessing of surgical instruments in compliance with AORN and AAMI guidelines. Healthmark has products to support every step of the reprocessing cycle of a surgical instrument, including safe transport of soiled instrumentation, cleaning and cleaning verification, visual inspection, packaging, labeling and sterilization. Visit our booth for in-booth CEU education and to see our line of custom printed PPE accessories! www.hmark.com

I. C. Medical, Inc. is a market-leading medical device company headquartered in Phoenix, Arizona that develops and manufactures devices and researches new techniques for surgical smoke collection and evacuation in surgical operating rooms. www.icmedical.com

or today Booth: 7352

For over 20 years OR Today has provided periop professionals with news and information about their profession. Stop by our booth to sign-up for your free subscription and learn how to earn FREE CE credits with our monthly webinar series! Stop by the booth for your FREE gift (while supplies last)! www.ortoday.com

the rUhof corporation Booth: 6441

Ruhof has a full line of surgical instrument, scope care and cleaning products to help you meet and exceed your decontamination challenges. Products include our multitiered enzymatic detergents, foam sprays, sponges, endoscopy kits, ATP Cleaning Verification and more. www.ruhof.com

For more information, visitaorn.org/surgicalexpo.com. WWW.ORTODAY.COM

WWW.ORTODAY.COM

February 2022 | OR TODAY

IN THE OR

market analysis

product focus

I.C. Medical

PenEvac1 and Non-Telescopic PenEvac I.C. Medical’s PenEvac1 and Non-Telescopic PenEvac are electrocautery pencils with integrated surgical smoke evacuation mechanisms. I.C. Medical’s new slim design non-telescopic smoke evacuation pencil features a slim profile for improved surgeon comfort and visibility. It includes universal blade compatibility and is designed to reduce cost. The Non-Telescopic PenEvac works with all smoke evacuation systems (Neptune, Medtronic, Conmed, Megadyne, etc.) and is on GPO contracts (GSA, Kaiser, HPG, Premier, etc.) I.C. Medical Inc. is an essential business and has remained open during the COVID-19 pandemic. The company is currently fully operational and here to support customers. PenEvac1 and Non-Telescopic PenEvac are made in the USA. Free samples are available.

Smoke Evacuation Systems Market On The Rise

For more information, visit icmedical.com.

Staff report he global smoke evacuation systems market size is expected to reach $285.5 million by 2028, according to a new report by Grand View Research Inc. The market is expected to expand at a CAGR of 7.4% from 2021 to 2028. Factors contributing to the growth of this market include an increase in medical tourism for cosmetic surgeries, electrosurgery procedures and increased product availability.

Elective and endoscopic procedures have been delayed due to the outbreak of COVID-19 to reduce the risk of transmission to other patients with chronic conditions. According to the Society of American Gastrointestinal and Endoscopic Surgeons, it is recommended to use electrosurgery pencils with attached smoke evacuators instead of monopolar electrosurgical and advanced bipolar devices and ultrasonic dissectors. Moreover, high-flow vacuum sources or filtration units are recommended during laparoscopic procedures. The market is thus 26

OR TODAY | February 2022

anticipated to experience gradual growth post-COVID-19 revival. The rising adoption of minimally invasive surgeries owing to their benefits such as shorter hospital stays, quick healing and fewer surgical incisions, is also expected to boost the market growth during the forecast period, as high-flow vacuum sources are used in a majority of minimally invasive surgeries. This is further supported by increasing technological advancements by market players, the prevalence of chronic diseases that require surgical procedures and the demand for better surgical equipment. Major market players are focused on launching technologically upgraded products in the market to enhance their presence. For instance, in January 2020, Symmetry Surgical Inc. acquired the O.R. Company that manufactures, develops and markets, innovative and high-quality surgical devices. Grand View Research pointed out the following market highlights: • The smoke evacuating system segment dominated the market in terms of revenue share in 2020 and is projected to wit-

ness a CAGR of over 7.8% from 2021 to 2028. Technological advancements by market players are expected to drive market growth. • North America dominated the market in terms of revenue share in 2020 because of the high number of aesthetic procedures in the region. • The industry participants are focusing on investing in acquisitions, collaborations, product launches and partnerships to gain a competitive edge. • The hospitals’ category holds the majority of the revenue share of around 42.9% in 2020 owing to high usage of high-flow vacuum sources in hospitals. In Asia-Pacific, the market is anticipated to witness a CAGR of around 9.7% over the forecast period owing to the high investments in R&D and consistent efforts being taken by global market players for commercializing their products at lower prices.

WWW.ORTODAY.COM

February 2022 | OR TODAY

CONMED

IN THE OR

Surgical Smoke Evacuation Solutions

product focus

IN THE OR

product focus

Clear the air in your OR with a comprehensive line of market-leading smoke evacuation products from CONMED Buffalo Filter. The PlumePen smoke evacuation pencils deliver three clinically differentiated options to accommodate diverse clinical needs. The PlumePen Elite features an ultra slim design and full blade reveal. The PlumePen Ultra offers a telescopic capture port with an advanced swivel design that allows for superior hand movement and less wrist drag. The PlumePen Pro is the lowest profile option, designed to closely mimic the ergonomics of a standard electrosurgical pencil. For more information, visit CONMED.com/MyHealthyOR.

Surgiform Saf-T-Vac

Henry Schein

The Saf-T-Vac by Surgiform is designed to make implementing a smoke evacuation system simple, without a capital equipment investment. This disposable and easy-to-use smoke evacuator integrates seamlessly with a surgeon’s preferred equipment, featuring a universal suction adapter that plugs into any available OR suction source. Surgical smoke should be evacuated no more than 2 inches from the surgical site to prevent irritation, infection and the transmission of viable cells. The Saf-T-Vac evacuates surgical smoke and fluid continuously at the source for ideal OR safe practices. It is easy to use and cost effective. It is made in the USA.

PlumeSafe Turbo PlumeSafe Turbo is a powerful portable surgical smoke evacuator designed with sufficient flow for the aesthetic market. It features turbo suction power, an interactive LCD display and filter tracking technology. It can easily be placed on a counter, shelf, floor or other location convenient to the operative area. PlumeSafe Turbo is compatible with a wide variety of CONMED Buffalo Filter ULPA filters and accessories to provide tailored solutions for multiple specialties.

For more information, visit www.surgiform.com.

OR TODAY | February 2022

WWW.ORTODAY.COM

February 2022 | OR TODAY

CE570 CE638

IN THE OR

continuing education

Reducing Pain During Minor Procedures for Pediatric Patients ix-year-old Sophia arrives in the ED with a 1.5 cm laceration of her scalp sustained when she fell off her bike. She is crying and anxious, and her mother is concerned about the repair procedure. Her mother reports Sophia had no loss of consciousness. Her physical exam is normal except for her scalp laceration. This is her first time to an ED and she tells the triage nurse that she is afraid of the “needle.” Her mother attempts to comfort her. Would you know what to do to help calm Sophia?

Initially, topical lidocaine/epinephrine/ tetracaine (LET) gel can be applied in triage to begin anesthetizing a wound. Twenty minutes later the wound will be numb, avoiding the need for an injection. Sophia is given the choice of several books to distract her attention. The child is placed in the mother’s lap in the “chest-to-chest” position so the child’s chest is against the mother’s chest. The mother is “hugging” the child for comfort and as a reminder to be still. During the procedure, you are careful to verbalize what Sophia is doing well, such as “you are doing a good job of holding still.” After the procedure, you offer Sophia the choice of a red or purple ice pop before discharge. Many minor procedures are regularly performed on emergency pediatric patients, such as IV starts, venipunctures, repair of lacerations, and incision and drainage of abscesses. By applying 30

OR TODAY | February 2022

evidence-based strategies, nurses can help reduce pain during these minor procedures. Nurses must first assess the level of pain and understand the barriers and options available for effective pain management in pediatric patients.

Barriers Pediatric pain is often underrecognized and undertreated in emergency and other medical settings.1, 2 The reasons are numerous, including inadequate assessment of pain because of varied developmental levels of pediatric patients and failure to use an adequate, developmentally appropriate pain-assessment scales.1,2 Another barrier includes healthcare professionals’ lack of knowledge about the pharmacological and non-pharmacological methods available for pain management.1,3 There’s also a lingering myth that pediatric patients don’t feel pain, but failure to prevent pain from even minor procedures can impact a child’s reaction to future, even non-painful procdures.1,2 In addition, children who present to an emergency setting may have a complicated history, or the provider may be unsure of the diagnosis and concerned that pain medication may mask symptoms that help in making a diagnosis.1 Pain medication titrated to the appropriate dose may aid diagnosis because it makes the child more comfortable and cooperative.1 Pain is also often undermedicated due to concerns about respiratory depression, over sedation, and lack of familiarity of pediatric dosing.1 The ED environment is filled with chaos and multiple patients, which can increase the anxiety of the

Relias LLC guarantees this educational program free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See Page 35 to learn how to earn CE credit for this module.

Goal and Objectives After taking this course, you should be able to: • Describe nonpharmacological and pharmacological methods that can be used to reduce pain in pediatric minor procedures. • Identify barriers surrounding pediatric pain management. • List opportunities where pain can be reduced in pediatric minor procedures

child and the parents, making the reduction of pain even more challenging.1 In addition, how the parent or caregiver reacts to the painful procedure may increase anxiety in the child.4 Anxiety also affects pain levels in children.1 Painful procedures for children can negatively impact them emotionally and may create post-traumatic stress symptoms for subsequent painful or non-painful procedures.1 NICU neonates continue to receive inconsistent pain control despite the American Academy of Pediatrics (AAP) recommendations for pain reduction.5 Children can have long-lasting, negative psychological effects from a painful proWWW.ORTODAY.COM

cedure.1,4,5 Infants as young as 25-weeks gestational age have pain pathways.5 Pain in these infants may “elicit a generalized or exaggerated response.”5 Consequences of pain include but are not limited to issues with brain development and stress responses that continue throughout childhood.4,5 Pain may even be more noxious in premature infants because of heightened sensory sensitivity.4,5

Assessment of Pain Pain is complex and dynamic.1 Healthcare providers must continually assess pain and remember that not all patients respond to pain in the same way.1 Pain can be affected by emotional, physical stimuli, and past experiences.1 A patient who has chronic levels of pain may react differently and may not report the pain the same as a patient who has not had chronic pain.1 Accrediting organizations, such as The Joint Commission, require pain assessment for all inpatients.1,4 Pain can and should be assessed by EMS before arrival to the ED.1 In addition, pain needs to be continually assessed throughout the patient’s stay.1,5 Healthcare providers must first determine the level of pain a pediatric patient is experiencing by choosing a scale based on the child’s developmental stage and situation.1,2 Self-report scales should be used with children who are developmentally able to provide subjective report of pain. The 0 to 10 pain scale can be used in children who can verbally report pain.4 Behavioral scales are available for use with those unable to self-report. There are multiple neonatal pain assessment scales but not a universally accepted method for assessing neonatal pain.4 The Neonatal Infant Pain Scale and the FLACC (Faces, Legs, Activity, Cry, and Consolability) behavioral observation tools can be used with pediatric patients who cannot provide a subjective report of pain.1,2,6 The FLACC Behavioral Pain Assessment Scale includes measures in the five categories of faces, legs, activWWW.ORTODAY.COM

ity, cry, and consolability.1,2 It has been demonstrated as an effective pain-management tool in multiple studies.1,2 After age 3, children are usually able to differentiate levels of pain if the assessment tool is geared to their developmental level.1,7 One self-report scale commonly used to assess pain in pediatric patients ages 3 and older is the WongBaker FACES Pain Rating Scale.1,4,7 The patient is instructed to point to the face that most accurately describes his or her pain.2,7 The faces range from a happy face to a very upset face.7,8 One change in a face is considered “clinically significant.”8 As a self-report tool, the clinician doing the assessment records the child’s response rather than the clinician’s perception of the child’s pain.7 The Visual Analog Scale is another tool that uses a straight line measuring 0 to 100 mm with the 0 end being no pain, and the 100-mm end being the worst pain the child can imagine.1,2,4,8 The Oucher Pain Scale is an ethnically based self-report tool that can generally be used in children older than 5 years of age.2 It is available with examples of facial expressions of African-American, Asian (boy or girl), Caucasian, First Nation (boy or girl), and Hispanic children experiencing pain.2 There are currently no validated tools for home assessment of pediatric pain.4 Home-assessment scales may be useful in the future to understand how pediatric patients respond to pain as well as pain related to family dynamics.4

Exam Room Ideally the pediatric patient is cared for in a single, “child-friendly” exam room.1 Rooms that contain child-friendly pictures or contain developmentally appropriate toys or games will help to minimize fear from being in a foreign environment.1

Parent Presence A variety of minor procedures are regularly performed on pediatric patients

in the ED, including venipunctures, IV starts, preparation for laceration repair, and incision and drainage of abscesses. There is evidence that the presence of a parent can cause less stress to the child.1,9 In addition, giving the parent the opportunity to be the “coach” has been shown to lower the child’s distress.1 Despite evidence that family presence has a positive impact on the distress children experience, it should not be required. Parents should be observed to ensure that they are not experiencing emotional stress from the child’s pain.1

Positioning Positioning of the child can also play a significant role during a procedure.9 When possible, allow the child to sit upright. Sitting in the parent’s lap provides an opportunity for the parent to be positive and supportive. Restraining the child often produces negative results.9

Distraction Child-life specialists as well as nurses and parents can help with distraction.1,2,3 Distraction is a commonly used intervention in the ED and can also be less costly than some pharmacological interventions.2 Child-life specialists are especially helpful as they are not involved in the performance of a procedure; they are solely focused on reducing the anxiety and perception of pain in the child and family.1 Distraction is effective at reducing pain from venipuncture.12 Numerous distracters can be made available such as cartoons, breathing exercises, ice massage, touching palm of hand, books, toys, music, video games, bubbles, TV, etc.1,2,8,10-12, 12b It is also appropriate to ensure the child’s developmental level matches the type of distraction.2 One study showed that kaleidoscopes and distraction cards can help decrease pain.10 In addition, distraction can include the child visually imagining a positive place such as the beach.2,11 Parental coaching is a method where parents are provided instruction on how February 2022 | OR TODAY

IN THE OR

continuing education to help the child by using toys, pacifiers, humor, or rocking.2,8 However, some studies do not support parental coaching being as effective as child-directed distractions.8,12 Cognitive interventions include a variety of distraction methods such as music and a topic of conversation not related to the procedure. 2 This may be helpful for older pediatric patients.2 Behavioral interventions include examples of distraction, including games, audiovisual distraction, breathing exercises, and muscle-relaxation methods.2,12 Breathing exercises were found to be an effective intervention for reducing stress in the patient and nurse.12

Anesthetics There are a variety of topical anesthetics available for use in the pediatric population.4 They include eutectic mixture of lidocaine 2.5% and prilocaine 2.5% (EMLA) cream; liposomal lidocaine 4% (LMX-4); tetracaine cream 2% (Ametop, Pontocaine); liposomal lidocaine 5% (LMX-5); lidocaine 7% and tetracaine 7% (S-caine); and benzocaine.4 LMX-4, LMX-5, Ametop, S-caine, or Pontocaine are not recommended for neonates since effectiveness and safety is not established.4 Most studies in the neonatal population have been done using EMLA.4 With accidental or when large amounts of local anesthetics are quickly absorbed, central nervous system and cardiac toxicity can occur.13 Local anesthetics can cause dysrhythmias and seizures in higher doses.4 Healthcare providers should not use local anesthetics in combination with epinephrine in the neonatal population.4 This can cause dysrhythmia and tissue necrosis.4 Toxicity of topical anesthetics can also cause a variety of adverse side effects which include but are not limited to life-threatening dysrhythmias and methemoglobinemia.4 Therefore, healthcare providers should be cautious with the choice of anesthetic.4 Over the counter topical benzocaine for teething pain should be used cautiously because the high concentration 32

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continuing education of benzocaine (20% = 200mg/mL) can easily cause overdose.4 The U.S. Food and Drug Administration has issued a black-box warning against use of OTC topical anesthetics for pain related to teething.4 In addition, the AAP does not recommend the use of topical anesthetics, in particular lidocaine or benzocaine, for teething pain.4 These products have led to seizures, dysrhythmias, respiratory depression, and death.4 The AAP recommends a chilled teething ring (not frozen) as well as “gentle” massage by a caregiver for teething pain.4 Topical lidocaine should be only used on intact skin.1 Lidocaine injected locally from a hypodermic syringe can be used for analgesia.1,3 It provides appropriate pain control, however, it does create the necessity of another injection which a child can find painful.3 The pain with injection of lidocaine for local anesthesia can be minimized by buffering the lidocaine with sodium bicarbonate, warming the lidocaine solution, injecting the lidocaine with a small needle, and performing the injection slowly into the tissues.1,3,13 Nurses should confirm there is no allergy to lidocaine/amide anesthetics before administrating lidocaine.1,13 A lidocaine needle-free injection is also available in the form of the J-Tip.3 J-Tip provides a needle-free delivery system for the local anesthetic with the use of a carbon dioxide injection.3 It provides pain relief in one to three minutes.3 However, J-Tip has not been studied in the newborn population.4 Studies have shown EMLA cream to be effective for pain control, and it can be used on intact skin before venipuncture procedures and in minor procedures in neonates.3 Other studies reveal that pain indicators, such as grimacing, crying length, heart rate, and oxygen saturation changes, are decreased in the neonatal population with use of EMLA before procedures that are expected to be painful.4 EMLA is not recommended for heel stick in the neonate as it does not appear to reduce pain and can even lengthen the procedure.4 The medication requires

application a minimum of 60 minutes before the procedure.1,3 Some sources indicate that application requires 45 to 60 minutes for pain relief, and that the area should be covered with an occlusive dressing.4 Genital mucous membrane absorption is faster with an effective onset time of five to ten minutes.3 Placement on inflamed or broken skin increases the risk for a “systemic pharmacological response.”3 Healthcare providers should be cautious when using the cream in young pediatric patients who may attempt to put it in their mouth or eyes.3 Anaphylaxis may also occur in patients. A common side effect is transient irritation of the skin, which is similar to other topical anesthetics.4 In addition, methemoglobinemia is possible in susceptible people, especially infants.1,3,4 Patients with G6PD deficiency or in patients who receive multiple doses are more at risk for methemoglobinemia.4 Healthcare providers should inquire if the child has recently taken sulfonamide antibiotics because EMLA is contraindicated with recent use of trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole because of potential additive effects or increased risk of adverse effects.1 Numerous clinical trials have shown effective pain relief with topical LMX4.3 Topical liposomal 4% lidocaine cream creates anesthesia in about 30 minutes.1,14 It has been shown to be effective with minor skin changes.14 LET contains lidocaine, epinephrine, and tetracaine can be made as either a liquid or gel by the hospital pharmacy.1 LET provides topical pain relief within 20 to 30 minutes and can be used for lacerations.1 Contraindications to LET include an allergy to the medication or if the wound is grossly contaminated.1 The time LET was placed should be noted.1 Since epinephrine is a strong vasoconstrictor, it is contraindicated in situations where it may result in compromised blood flow.13 Also, patients who have diabetes, hypertension, heart block, or cerebral vascular disease may be particularly sensitive to the effects of epinephrine.13 WWW.ORTODAY.COM

Lidocaine and Tetracaine Topical Patch 70mg/70mg has a mild heating component which can produce its effect quicker by heat.1,3 Another option is vapocoolant sprays such as Pain Ease. These anesthetics work by cooling the skin.3 They have a quick onset of action, and pain relief lasts for less than one minute.3 Vapocoolant sprays seem to show effectiveness in adults; however, the cold sensation may make it less tolerable in the pediatric population.1 Side effects of note are allergic reaction contact dermatitis, hypopigmentation, and atrophic scarring.3,15 Vapocoolants cause eye irritation and should not be used on other mucous membranes with the exception of Pain Ease, which may be used on membranes other than genital.3 Pain Ease has been found to provide transient anesthesia lasting 60 seconds within seven to 10 seconds of application by evaporationinduced skin cooling. Ice applied locally also has been shown to be a pain relief option along with ice combined with vibration.1,8 See prescribing information for dosing, appropriate age for use, application procedures, and full side-effect profiles of these above anesthetic medications.

Neonates Swaddling, non-nutritive sucking, and massage are reported to have “variable” responses in managing pain or stress in infants.5,14 Skin-to-skin contact with and without sucrose/glucose has also been documented to alleviate pain in the preterm and term neonate.5,4 Skin-to-skin contact is also called Kangaroo Care due to its similarity between the care of a kangaroo and its offspring.4 Skin-to-skin contact, positioning, and non-nutritive sucking have been shown to decrease pain most effectively when used in adjunct with other non-pharmacological therapies such as oral sucrose or breastfeeding.4 Breastfeeding is also found to be effective in decreasing the infants’ perception of pain.4,5 Similar results have been WWW.ORTODAY.COM

seen with oral sucrose and glucose as well as milk from pacifier or syringe.5 Breastfeeding and sucrose or glucose in combination have also been shown to reduce pain.4 In addition, providing “sensorial stimulation,” which includes stimulation of multiple senses, has been shown to help during minor procedural pain.4,5 For example, the neonate can be given oral sucrose while at the same time receiving tactile stimulation from a facial massage and auditory stimulation from soft speaking.4 Sweet-tasting solutions are a type of non-pharmacological pain intervention.15 Oral sucrose is a commonly employed analgesic agent, most effective in infants younger than 3 months.4 Glucose appears to be an alternative to sucrose, however, as with sucrose, there is no standard recommended dose.5 Studies have shown that oral sucrose and/or glucose decreases heart rate variation, reduces crying time and facial grimacing, lowers pain scores.4, 15 However, despite numerous studies, there remain questions about the mechanism of action, appropriate dose, long-term effects, and analgesic versus soothing response for both sucrose and glucose.5,16 A 24% sucrose or 20% to 30% glucose solution is suggested, at doses that range from 12 to 120 mg. Solutions with lower osmolarity are recommended for use in premature infants as solutions in the 24% to 33% range lend to a higher risk of necrotizing enterocolitis in that population.4 These solutions should be documented as a medication when used.5 It appears that sucrose is most effective when given about two minutes before a procedure, and its effects remain for about four minutes.5 Sucrose administered in more than one dose, such as pre and post procedure, seems to be more effective than a single dose.4 Glucose (20% to 30%) solution has been shown to be effective in less invasive and shorter procedures.4 Of note, glucose and sucrose appear to be most effective when used as an adjunct with other non-pharmacologic therapies

such as non-nutritive sucking or sensorial stimulation.4 Acetaminophen is recommended for mild-to-moderate painful intervention in neonates.4 These procedures include finger and heel sticks, removal of adhesives, circumcision, and dressing changes.4 Neonates have slower clearance than older children so healthcare providers should be aware to dose less frequently.4 See prescribing information for more details on dosing in the neonatal population.4 Side effects can include renal and hepatic toxicity.4 Dosing is weight based and can be administered in syrup, suppository, or chewable tablet form. Nonsteroidal anti-inflammatory drugs should not be used in the neonatal population.4 Not only is there a lack of studies on the use of opioids, benzodiazepines, and other medications in the neonate, those that do exist have produced conflicting results.5 These medications may cause respiratory depression and decreased blood pressure.4,5 Healthcare providers should weigh the risks and benefits of these medications with current evidence-based information.5

Summary Now that you have finished viewing the course content, you should have learned the following: Despite the evidence about effective pain management in pediatric patients, healthcare providers don’t consistently see these methods applied in clinical practice.1,5 Using parental presence, positioning, distraction, breastfeeding, application of local ice, topical vapocoolants, topical anesthetics, and oral sucrose/glucose can significantly reduce pain. Nurses should become familiar with pain-reduction methods and encourage the use of nonpharmacological and pharmacological methods to reduce pediatric pain. Experts in the field recommend that healthcare organizations serving the pediatric population implement strategies to minimize the number of painful procedures neonates and chilFebruary 2022 | OR TODAY

IN THE OR

CE638

continuing education

How to Earn Continuing Education Credit agementcpg.pdf?sfvrsn=c650e1d6_12. Developed 2014. Updated 2018. Accessed December 9, 2019.

This course was created or revised by Valerie Probstfeld, MSN, RN, FNP-BC. Valerie Probstfeld, MSN, RN, FNP-BC, is a family nurse practitioner. She obtained her MSN from Yale University and has experience in pediatric neurology and retail health. She is adjunct faculty at Texas Woman’s University.. The content for this course was edited or revised by Elizabeth Kellerman MSN RN. Elizabeth Kellerman, MSN, RN, started nursing in 2007 after graduating from Samuel Merritt University in Oakland, California. While working in a critical care unit at Sutter Mills-Peninsula Hospital she earned her CCRN and TNCC. Her experience and knowledge led her to nursing education where she taught at a community college while working to receive her Master’s in Nurse Education at Western Carolina University. As a nursing instructor, she spent time in many types of care settings including medical-surgical inpatient and community living centers. Her passion for education and training has led her to a position as a content writer at Relias. Editor’s Note: Cathy Dykes, MS, RN, CCRC, CCRP, CGRN; Lois Jane Jones, RN; and Maria Morales, MSN, RN, CPAN; past authors of this educational activity, have not had an opportunity to influence the content of this current version.

OR TODAY | February 2022

Clinical Vignette Five-year-old Zoe fell on the playground and sustained a 2-cm laceration of the forehead about an hour before arriving in the ED. She had no loss of consciousness. Zoe, who is accompanied by her mother, is anxious and crying. 1. Which scale is most appropriate for assessing Zoe’s pain? A. FLACC Behavioral Pain Assessment Scale B. Pediatric pain C. Visual Analog Scale D. Wong-Baker FACES Pain Scale 2. In preparation for Zoe’s laceration repair, what position should you place her in to help allay her anxiety? A. Lying prone on the stretcher B. Lying supine on the stretcher C. Sitting chest to chest with her mother D. Standing at the side of the stretcher 3. All the following are useful pain relief strategies for Zoe EXCEPT: A. Distraction with cartoons B. Sucrose administration C. Parent in exam room D. Liquid acetaminophen syrup 4. Methods to help decrease pain in the neonate include all EXCEPT: A. Breastfeeding B. Let them “cry it out” C. Oral sucrose D. Non-nutritive sucking

Sparks LA, Setlik J, Luhman J. Parental holding and positioning to decrease IV distress in young children: a randomized controlled trial. J Pediatr Nurs. 2007;22(6):440-447. doi:10.1016/j.pedn.2007.04.010.

10.

Canbulat N, Inal S, Sönmezer H. Efficacy of distraction methods on procedural pain and anxiety by applying distraction cards and kaleidoscope in children. Asian Nurs Res (Korean Soc Sci). 2014;8(1):23-28. doi: 10.1016/j.anr.2013.12.001.

11.

Blount RL, Schaen ER, Cohen LL. Commentary: Current status and future directions in acute pediatric pain assessment and treatment. J Pediatr Psychol. 1999;24(2):150-152.

12.

Chambers CT, Taddio A, Uman LS, McMurty CM; HELPinKIDS Team. Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review. Clin Ther. 2009;31(Suppl 2):S77-S103. doi:10.1016/J.c1lnthera.2009.07.023.

References 1.

Fein JA, Zempsky WT, Cravero JP; Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine; American Academy of Pediatrics. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2012;130(5):e1391-e1405. doi:10.1542/peds.2012-2536. Srouji R, Ratnapalan S, Schneeweiss S. Pain in children: assessment and nonpharmacological management. Int J Pediatr. 2010;2010:474838. doi:10.1155/2010/474838. Zempsky WT. Pharmacologic approaches for reducing venous access pain in children. Pediatrics. 2008;122(Suppl 3):s140-s153. doi: 10.1542/peds.2008-1055g. Witt N, Coynor S, Edwards C, Bradshaw H. A guide to pain assessment and management in the neonate. Curr Emerg Hosp Med Rep. 2016;4:1-10. doi: 10.1007/s40138-016-0089-y. Committee on Fetus and Newborn; Section on Anesthesiology and Pain Medicine. Prevention and management of procedural pain in the neonate: an update. Pediatrics. 2016;137(2):e20154271. doi: 10.1542/ peds.2015-4271.

Voepel-Lewis T, Zanotti J, Dammeyer JA, Merkel S. Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. Am J Crit Care. 2010;19(1):55-61. doi: 10.4037/ajcc2010624.

Wong-Baker FACES Pain Rating Scale. Wong-Baker FACES Foundation Web site. www.WongBakerFACES.org. Accessed December 9, 2019

2018 Emergency Nurses Association Clinical Practice Guideline Committee. Clinical practice guideline: needlerelated procedural pain in pediatric patients. Emergency Nurses Association Web site. https://www.ena.org/ docs/default-source/resource-library/ practice-resources/cpg/pedpainman-

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12b. Rezai, M. S., Goudarzian, A. H., Jafari-Koulaee, A., & Bagheri-Nesami, M. (2016). The effect of distraction techniques on the pain of venipuncture in children: A systematic review. Journal of Pediatric Review, 5(1), 1–11. doi:10.17795/jpr-9459. 13.

Archar S, Kundu S. Principles of office anesthesia: part 1. Infiltrative anesthesia. Am Fam Physician. 2002;66(1):91-94. http://www.aafp.org/ afp/2002/0701/p91.html. Accessed December 9, 2019.

14.

Taddio A, Soin HK, Schuh S, Koren G, Scolnik D. Liposomal lidocaine to improve procedural success rates and reduce procedural pain among children: A randomized controlled trial. CMAJ. 2005;172(13):16911695. doi: 10.1503/cmaj.045316.

15.

Farion KJ, Splinter KL, Newhook K, Gaboury I, Splinter WM. The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial. CMAJ. 2008;179(1):31-36. doi: 10.1503/ cmaj.070874.

15b. Perry M, Tan Z, Chen J, Weidig T, Xu W, Cong XS. Neonatal Pain: Perceptions and Current Practice. Crit Care Nurs Clin North Am. 2018;30(4):549–561. doi:10.1016/j.cnc.2018.07.013 16.

Curtis SJ, Jou H, Ali S, Vandermeer B, Klassen T. A randomized controlled trial of sucrose and/or pacifier as analgesia for infants receiving venipuncture in a pediatric emergency department. BMC Pediatr. 2007;7:27. doi: 10.1186/1471-2431-7-27.

Clinical VignettE ANSWERS 1. Answer: D. After 3 years of age, children are usually able to differentiate levels of pain if the assessment tool is geared to their developmental level. The FACES Pain Scale can be used in children ages 3 and older 2. Answer: C. Sitting chest to chest with her mother would be a comforting position for Zoe. 3. Answer:B. Oral sucrose is a commonly employed analgesic agent, most effective in infants younger than 3 months. 4. Answer: B. Breastfeeding, non-nutritive sucking, and oral sucrose are a few options that may help decrease pain in the neonate. Pain should be addressed in the neonate.

dren are exposed to and improve the use of non-pharmacological therapies for pain management in this vulnerable population.5

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

Deadline Courses must be completed by 2/28/2023 3. If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer. 4. Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test. 5. All users must complete the evaluation process to complete course. You will be able to view a certificate on screen and print or save it for your records.

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

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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

February 2022 | OR TODAY

Patient Prep Powers Successful Surgeries

“Each patient should be given the opportunity to clarify instructions and voice questions and concerns.” - David Shapiro

By DON sadler

ne of the biggest keys to successful surgical O outcomes is thorough patient prep before the surgery. There are many different components

to effective preoperative patient prep, with the most important usually being clear communication between the patient and the preadmission team.

What is Preoperative Patient Prep? Alexander Hannenberg, M.D., a perioperative safety consultant and co-founder of ORDxRx Solutions for Surgical Safety, refers to preoperative patient prep as “a process to address modifiable risks that contribute to patient complications or impaired recovery.” Failure to do preop patient prep thoroughly and effectively can potentially lead to a number of negative outcomes. “These include prolonged hospital stays, returns to acute care, poor healing, infections and cardiovascular or respiratory complications,” says Hannenberg. Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, the director of evidence-based perioperative practice for the Association of periOperative Registered Nurses (AORN), concurs. She emphasizes the importance of effective patient prep in minimizing the risk of surgical site infections (SSIs). “Preoperative patient skin antisepsis reduces the patient’s risk of developing an SSI by removing soil and transient microorganisms at the surgical site,” says Spruce. “Reducing the number of bacteria on the skin near the surgical incision lowers the risk of contaminating the surgical incision site.” Preoperative decolonization, preoperative bathing and hair management at the surgical site are all part of preparing the skin for antisepsis. “This contributes to a reduction of microorganisms on the skin,” says Spruce. David Shapiro, M.D., an anesthesiologist at Red Hills Surgical Center in Tallahassee, Florida, believes that the biggest benefit of a rigorous preop evaluation is determining the most appropriate setting for a patient to undergo a specific procedure at a specific time. “A thorough preop evaluation should be structured to assist clinicians in their decisions regarding how to deliver the most appropriate care to each of their patients,” says Shapiro. “From the patient’s perspective, having these determinations made prior to the immediate preoperative timeframe goes a long way toward avoiding the possibility of a same-day cancellation.” “As surgical professionals, we often forget to appreciate how upsetting cancellations can be for our patients,” Shapiro adds.

Keys to Effective Preoperative Prep Spruce offers the following tips for effective preoperative patient prep: • Preop skin care – “For optimal effectiveness of the antiseptic, it is necessary to adhere to the time allotment for application before the surgical procedure as outlined in manufacturer’s instructions and perform a standard36

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February 2022 | OR TODAY

“Education is critical to ensuring that patients get the most benefit from their surgery.” - Beverly Kirchner ized surgical site preparation protocol,” says Spruce. “This includes site preparation before application of the skin antiseptic, application of the antiseptic using sterile technique and safety measures to prevent patient injury related to antiseptic use.” • Fasting protocols – While the fasting guidelines of various anesthesia societies support allowing clear fluids up to two hours and solid food up to six hours before anesthesia, Spruce notes that many patients receive instructions to not eat or drink anything after midnight before the day of their procedure. • Antibiotic protocols – Preoperative antibiotic selection to help reduce the risk of postop infection is based on the type of surgical procedure. “Surgeons will select antibiotics for patients based on numerous factors such as cost, safety, ease of administration, pharmacokinetic profile, bactericidal activity and hospital resistance patterns,” says Spruce. • Decolonization program – Spruce says it’s important for facilities to convene an interdisciplinary team to determine the need to implement a preoperative decolonization program for Staphylococcus aureus. “Prophylaxis for staph local epidemiology, patient risk factors, health care resources and operative or invasive procedure risk factors are key considerations for development of an optimal decolonization program,” says Spruce. • Diabetic, radiology and pregnancy testing – These tests should be completed before the day of surgery so delays aren’t encountered. “Anesthesia providers may order additional tests based on the patient’s condition and these should also be completed prior to the patient’s arrival for surgery,” says Spruce.

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Preoperative Patient Interviews Preoperative interviews are important when it comes to identifying patients in need of prehabilitation, says Hannenberg. “These interviews are part of multifaceted triage that can include questionnaires, manual or automated extraction of data from the EHR and clinician application of screening algorithms,” he says. Doing preop interviews by telephone or virtually via Zoom calls has become more common during the pandemic. “Virtual preoperative visits eliminate the need for some patients to come to the facility for interviews and testing, which reduces potential exposure to COVID-19 from other patients and community members,” says Spruce. “Patients can be screened for medical optimization and given preop instructions over a Zoom call.” Regardless of how the preop interview is conducted, patients should be given clear, standardized instructions for preoperative bathing and other interventions and allowed the opportunity to ask questions. “Make sure patients understand the rationale behind the instructions so they know the importance of following them,” says Spruce. Shapiro stresses the importance of setting expectations during the preop interview. “Often, there are tasks or protocols that are required of patients to optimize their presurgical status,” he says. Examples include discontinuance of medications or the addition of measures like skin antisepsis that can contribute to a successful episode of care. “This teaching should not only provide reassurance to the patient, but it should also reinforce what the outcomes and timeframe of the procedure are expected to be,” says Shapiro. Shapiro believes that the preop interview should be customized to account for whatever level of understanding the patient may bring to the conversation. “Each patient should be given the opportunity to clarify instructions and voice questions and concerns,” he says. “It’s so important that patients arrive at the facility knowing there are compas-

sionate and caring health care professionals who will be managing their care on their behalf,” Shapiro adds. “This dynamic starts with the preoperative communication and can chart the course toward the optimal outcome that we desire and the patient both expects and deserves.” Hannenberg recommends a deliberate and stepwise implementation plan for going beyond patient assessment to preop patient optimization. “The work can be thought of in several dimensions including disease condition or patient population stratified by age, surgical case type or even specific surgical practice,” he says. “There are few, if any, institutions that can integrate their entire surgical population into a comprehensive assessment-optimization process, so an incremental approach makes the most sense,” Hannenberg adds. “There will be crosscutting lessons learned with implementation for a particular patient cohort that will make the expansion of scope smoother and more successful.”

Surgical Scheduling and ERAS Of course, scheduling is an important part of the patient preadmission process. “This is the first place where critical patient information is captured and relayed to the surgical team,” says Spruce. “Surgical schedulers should be sure to relay critical information to the preoperative team.” This critical information typically includes: • The correct patient and procedure, including site and side • Completion of the patient history and physical • Completion of required consultations • Informed consent • Preoperative orders • Anesthesia consult as needed • Implant, instrumentation and equipment needs • The name of the patient’s caregiver who will be present at the preoperative visit Enhanced Recovery After Surgery (or ERAS) programs can go a long way WWW.ORTODAY.COM

toward helping patients improve their surgical recovery. First developed in Europe, ERAS has been touted as the evidence-based new paradigm of perioperative care. There are five consensus practical care components of ERAS: 1. 2. 3. 4. 5.

Preoperative carbohydrate loading Interactive patient notification technology Early resumption of diet Setting pain management expectations Early mobility

Among the measurable benefits of ERAS programs at Scripps Memorial Hospital, which participated in a collaboration in 2021 with Cardinal Health and ClearFast Inc., were: • A 50% reduction in patient length of stay • A roughly two-thirds reduction in the use of opioids among surgical patients • A statistically significant reduction in SSIs • A statistically significant reduction in surgical patient readmissions “ERAS programs are a new way of thinking about the entire perioperative setting and how the process impacts patients, as well as how patients can impact their own recovery,” says Spruce. “There are specific detailed protocols to use in specific patients, but all patients can benefit from ERAS programs.” For example, patients can improve their nutrition and physical fitness prior to surgery to help diminish the impact of the stress of the procedure on their bodies and promote faster recovery.

ERAS Protocols for Carbohydrate Loading Carbohydrate loading prior to surgery can be accomplished by consuming preoperative beverages like ClearFast, an iso-osmolar, complex carbohydraterich beverage that contains neither fat nor protein. According to ClearFast Inc. founder M. Lou Marsh, MD, the full ERAS protocol calls for two to three 12-ounce servings of the beverage during the 12 hours prior to surgery. WWW.ORTODAY.COM

“Not only are these patients more comfortable, hydrated and nourished going into surgery, but the ERAS literature strongly suggests a reduction in the incidences of de novo postop insulin resistance and the attendant hyperglycemia it causes,” says Marsh. “This metabolic aberration often leads to surgical site infections that are responsible for prolonged hospital lengths of stay.” According to Marsh, preop carbohydrate loading remains one of the few integral parts of most, if not all, ongoing ERAS programs nationally. “And ClearFast appears to be the beverage of choice,” she says. “Today, ClearFast is euphemistically referred to as the ‘Beverage of ERAS.’ ” Anecdotally and in published studies, patients who consumed ClearFast before surgery have overwhelmingly said they felt neither hungry nor thirsty during the immediate preop period. “This translates into fewer incidences of patients breaking the requisite preop fasting from all solids and other non-clear liquids before their scheduled surgeries,” says Marsh. “This results in a significant reduction in the number of delayed or canceled procedures due to failure by patients to fast.”

Why Patient Education is Critical

SOURCES ALEXANDER HANNENBERG,

M.D., a perioperative safety consultant and co-founder of ORDxRx Solutions for Surgical Safety

BEVERLY KIRCHNER, BSN, RN, CNOR, CNAMB,

DAVID SHAPIRO,

M.D., an anesthesiologist at Red Hills Surgical Center in Tallahassee, Florida

LISA SPRUCE,

DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, the director of evidence-based perioperative practice for the Association of periOperative Registered Nurses (AORN)

M. LOU MARSH, MD and ClearFast Inc. founder

Beverly Kirchner, BSN, RN, CNOR, CNAMB, stresses the importance of patient education when it comes to successful preoperative prep. “Education is critical to ensuring that patients get the most benefit from their surgery,” she says. “Suppose you stick to the preadmission calls and physical prep like anesthesia NPO,” says Kirchner. “You would not discuss the preoperative education or the nursing history and physical, which are critical to ensuring that the patient meets the admission criteria.” The bottom line, says Kirchner, is that patients can’t be compliant if they don’t understand the instructions provided during preoperative prep. “And this may lead to poor surgical outcomes,” she says.

February 2022 | OR TODAY

Spotlight ON

SPOT LIGHT

ON: LAURA

wenty years ago, when she started out at Laramie County Community College in Cheyenne, Wyoming, as a young, single mom, Laura Nelson had planned on preparing for a career as an X-ray technician. But by the time she’d gotten to anatomy class, her instructor recognized that the certificate program wasn’t likely to hold her interest.

“He said to me and my friend, ‘I don’t think you guys are going to like what you’re doing; I think you want to go into nursing,’” Nelson recalled. “You had to take the nursing entrance test (NET) to apply to the nursing school,” she said, “so we called the nursing school. They said, ‘It’s the last day to test, it’s a four-hour test, and we close in an hour.” “My philosophy my entire life has been that your life is a result of the choices that you make,” she said. “I decided to take the next step, and the next step.” Nelson aced the test and got into nursing school on her first try. But in her early clinical rotations, when she was assigned to a hospice rotation, Nelson began to think she’d made a serious error. “I’m not the most huggy, soft person in the world, so when I went to hospice, I was crying every day,” she said. “It’s so sad. And my friend who was a surgical technician said, ‘You’ve just got to get to the OR. Go watch a case and see what this is like.” Nelson won one of five slots in the perioperative 101 course, and from that point on, her path was much clearer. After graduating with an associate’s degree, she took a job at United Medical Center in Cheyenne. With her first vacation pay, she decided to take her kids to San Diego for a trip to Sea World. While she was there, reading a newspaper on the beach, Nelson spotted a job opening at the trauma team at the Navy Medical Center San Diego. She applied during her vacation, and got a job offer from the hospital upon returning home to Wyoming. “I worked on the ortho trauma team there, and that was probably one of the most incredible experiences of my life,” Nelson said. “It was at the height of the Afghan War, so we would get all the West Coast Navy and Marines who were injured in Afghanistan.” “Triple amputations, multiple reconstructive surgeries; these are young, young men,” she said. “That is a very humbling experience.” In addition to circulating, Nelson also was tasked with teaching Navy corpsmen the skills of a surgical technician so they would be able to provide emergency aid in forward operating bases that didn’t always have a nurse. She quickly learned that she not only enjoyed teaching new OR staffers, but that she was good at it, too. Nelson began to consider Officer Candidate School (OCS), but knew she’d need a bachelor’s degree to get in. So, with four small children at home and a husband who was deployed, Nelson

OR TODAY | February 2022

RN, BSN, CNOR, and MBA Candidate

NELSON

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enrolled in Chamberlain College of Nursing, and completed her degree online in about 13 months – with a perfect 4.0 GPA. But she never made it to OCS: her husband was ordered to Guantanamo Bay, Cuba, and without any other family support in San Diego, Nelson and the children relocated to San Antonio, Texas. There she took a job on the surgical research team at Fort Sam Houston that was “totally different from anything I’d done before.” “It was the first time I had to wear dress clothes and not scrub pajamas,” Nelson laughed. “It was interesting because we were learning cutting-edge techniques that could change the face of surgery, but then there’s also times when you do nothing because any patient outcomes have to be investigated. You could show up to work for weeks and not be able to work on your studies.” After a year, the family regrouped. Nelson’s husband at the time was getting ready to complete his military service, and so they asked the children where they’d like to go next. After a vote, they returned to southern Oregon, and Nelson took a job at Asante Rogue Regional Medical Center, the hospital at which she was born. Within a year, she was promoted to charge nurse. “When I got here, I learned how to scrub,” Nelson said. “It was very different for me; really fun. The pace is a little faster with no residents; the surgeons are incredibly skilled, and very fast.” “I’m a very good puzzle person and people person,” she said. “Surgery scheduling is like Tetris: if you can get the right people in the right rooms at the right time, everything goes very smoothly. I really enjoyed matching up the right people with the right outcomes, and having fun. Everybody wants to participate, and everything gets done sooner.” Today, Nelson has been at Asante for nine years; her children are now 22, 20, 14 and 13. After backing up different team leaders and charge nurses, she returned to regular bedside circulating for a time before taking on the role of manger of surgical services. Amid a nationwide nursing shortage, the needs of her position have only gotten more demanding during the novel coronavirus (COVID-19) pandemic. In the summer of 2021, rural Jackson County, Oregon, where Asante is located, had the highest per-capita COVID-19 case rate in the nation. “We were already short nurses across the nation, and now here comes the pandemic,” Nelson said. “We watched coworkers die, patients die; more sad things than you can imagine, and people are protesting outside because they don’t want their shot.” “We don’t want to make national news for being unvaccinated and ignorant and letting our people die,” she said. “Because of all that hospital space needed for COVID patients, we shut down surgery because people hadn’t gotten their shots. That’s a really weird thing to understand.” Nonetheless, Nelson works to make her hospital a comfortable place for herself and her coworkers. During the summer and winter months, she hosts annual parties for colleagues who are away from their families, and gets out her own wanderlust on vacations. The best advice she has for her fellow nurses is to remember that their jobs afford them opportunities unlike those in any other career. “Treat every single person who goes on the table like someone you love the most,” Nelson said. “This is your mom. This is your daughter. This is your sister. We have the potential to change someone’s life – to hold their hand, take amazing care of them, and change their life.” “That gives you a different kind of feeling,” she said. “It isn’t always a paycheck. It’s a purpose.” February 2022 | OR TODAY

OUT OF THE OR

health

improved depression symptoms over control conditions, but the effect was not as strong as that found in a similar meta-analysis of face-to-face psychotherapy. There were not enough studies in the current meta-analysis to directly compare digital interventions to face-to-face psychotherapy, and researchers found no studies comparing digital strategies with drug therapy. The digital treatments that involved a human component, whether in the form of feedback on assignments or technical assistance, were the most effective in reducing depression symptoms. This may be partially explained by the fact that a human component increased the likelihood that participants would complete the full intervention, and compliance with therapy is linked to better outcomes, according to Moshe. One finding that concerned Moshe was that only about half of participants actually completed the full treatment. That number was even lower (25%) in studies conducted in real-world health care settings compared with controlled laboratory experiments. This may help explain why treatments tested in real-world settings were less effective

COMPUTER-, SMARTPHONEBASED TREATMENTS REDUCE DEPRESSION SYMPTOMS omputer- and smartphone-based treatments appear to be effective in reducing symptoms of depression, and while it remains unclear whether they are as effective as face-to-face psychotherapy, they offer a promising alternative to address the growing mental health needs spawned by the COVID-19 pandemic, according to research published by the American Psychological Association.

“The year 2020 marked 30 years since the first paper was published on a digital intervention for the treatment of depression. It also marked an unparalleled inflection point in the worldwide conversion of mental health services from face-to-face delivery to remote, digital solutions in response to the COVID-19 pandemic,” said lead author Isaac Moshe, MA, a doctoral candidate at the University of Helsinki. “Given the accelerated adoption of digital interventions, it is both timely and important to ask to what extent digital interventions are effective in the treatment of depression, whether they may provide viable alternatives to face-to-face psychotherapy beyond the lab and what are the key factors that moderate outcomes.” The research was published in the journal Psychological Bulletin. Digital interventions typically require patients to log in to a software program, website or app to read, watch, listen to and interact with content structured as a series of modules or lessons. Individuals often receive home42

OR TODAY | February 2022

work assignments relating to the modules and regularly complete digitally administered questionnaires relevant to their presenting problems. This allows clinicians to monitor patients’ progress and outcomes in cases where digital interventions include human support. Digital interventions are not the same as teletherapy, which has gotten much attention during the pandemic, according to Moshe. Teletherapy uses videoconferencing or telephone services to facilitate one-on-one psychotherapy. “Digital interventions have been proposed as a way of meeting the unmet demand for psychological treatment,” Moshe said. “As digital interventions are being increasingly adopted within both private and public health care systems, we set out to understand whether these treatments are as effective as traditional face-to-face therapy, to what extent human support has an impact on outcomes and whether the benefits found in lab settings transfer to real-world settings.” Researchers conducted a meta-analysis of 83 studies testing digital applications for treating depression, dating as far back as 1990 and involving more than 15,000 participants in total, 80% of adults and 69.5% of women. All of the studies were randomized controlled trials comparing a digital intervention treatment to either an inactive control (e.g., waitlist control or no treatment at all) or an active comparison condition (e.g., treatment as usual or face-to-face psychotherapy) and primarily focused on individuals with mild to moderate depression symptoms. Overall, researchers found that digital interventions WWW.ORTODAY.COM

than those tested in laboratories. “The COVID-19 pandemic has had a major impact on mental health across the globe. Depression is predicted to be the leading cause of lost life years due to illness by 2030. At the same time, less than 1 in 5 people receive appropriate treatment, and less than 1 in 27 in low-income settings. A major reason for this is the lack of trained health care providers,” he said. “Overall, our findings from effectiveness studies suggest that digital interventions may have a valuable role to play as part of the treatment offering in routine care, especially when accompanied by some sort of human guidance.” Article: “Digital interventions for the treatment of depression: A meta-analytic review,” by Isaac Moshe, MA, and Laura PulkkiRåback, PhD, University of Helsinki; Yannik Terhorst, MS, Matthias Domhardt, PhD, Paula Philippi, BSc, and Harald Baumeister, PhD, Ulm University; Pim Cuijpers, PhD, Vrije Universiteit Amsterdam; Ioana Cristea, PhD, University of Pavia; and Lasse Sander, PhD, Albert-Ludwigs-Universitat Freiburg. Psychological Bulletin, published online Dec. 13, 2021.

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February 2022 | OR TODAY

OUT OF THE OR fitness

Happy Healthy Hips By Miguel J. Ortiz he hip complex in general is such a unique bone with two very important hip joints that are responsible for so much of our movement. It’s the foundation for your spine and the anchor for your legs. Playing such a vital role in our day-to-day life, it’s very important to keep your hips mobile and ready to take on the day.

Unfortunately, many don’t realize how important hip maintenance is until it’s too late. The good news is that it doesn’t take the hardest exercises or a lot of time. Because so much of our life consists of routine movements – like sitting or standing – all we need to do is create a little constancy. To do so, I want you to perform these three movements for just 10-15 minutes daily and you’ll be well on your way to healthy and happier hips. The first move I call an initial hip opener (youtu.be/LYotgCfEM-s). There are two critical muscle groups that heavily affect the hips – your adductors (inner thighs) and hamstrings. With this exercise you’ll be able to target both during different phases of the movement. We want to start in a quadruped position, start by bringing your left leg up close to your left hand. Remove your left hand from the ground and place it on your knee if you need help with a little bit of balance. In this exaggerated kneeling split position, you should feel a stretch in your left inner thigh. Try to 44

OR TODAY | February 2022

keep your chest up and drive your hips toward the ground. In order to target the hamstring of the same left leg, we will transition by sitting the butt back, allowing the left leg to straighten as we do so. This will provide a deep stretch in your left hamstring and, in order to maintain balance, simply place your left hand back on the ground to help maintain stability. Then, return back to that forward kneeling position allowing your left knee to bend. The second move is a half kneeling quad stretch and reach (youtu.be/ dI07ZFMbGs4). Many people find it hard to really stretch their hip flexor, especially because the movement usually starts with reaching back and grabbing your foot behind your back. This isn’t the greatest way to perform this stretch – even though it’s so common. By doing this stretch with assistance (using a bench, couch, chair or wall) you will be able to increase your ability to get deeper into the stretch without compromising your lower back. Start on the ground and lift your right leg until your shoelaces are on the bench. Then, take your left knee and lift it off the ground placing your left foot on the floor, so you are in a split position. Once you begin to sit upright in this half kneeling position you should begin to feel the stretch through the front quad and hip flexor. To get deeper into the stretch and open up the hips further, engage your right glute and reach your hand toward the ceiling.

Our last movement is common and very important because this muscle group is responsible for the strength and stability of the hips. Here we are targeting our glutes, and by utilizing some assistance it will allow us to get much deeper. I give you the elevated pigeon pose and lean (youtu.be/HzCFbnSu3Mk). I recommend using a bench or the side of your bed for assistance. By using elevation, it allows the back leg to drop giving us more room to stretch our front leg’s glute. Start with your hand on the bench for stability and bring one leg up until the outside of your knee and leg are resting on the bench. Once in position, simply by lifting your chest up and squaring your hips forward you’ll immediately feel a glute stretch. To get deeper into the movement try leaning forward and bringing your opposite shoulder across the body. Have fun with these movements and remember the key to happy hips is consistent and proper mobility. We just need to do these three exercises for 1015 minutes each day to really feel the effects and have our hips ready to take on the day. Miguel J. Ortiz is a personal trainer in Atlanta, Georgia. He is a Master Trainer for Pain-Free Performance and a Certified Nutritional Consultant with more than a decade of professional experience. He can be found on Instagram at @migueljortiz. You can find his YouTube channel at tinyurl.com/ORTfitness. WWW.ORTODAY.COM

Understanding Your Motives for Goal Setting

OUT OF THE OR EQ Factor

By daniel bobinski, M.Ed. n this second installment of our series on Stephen Covey’s “Seven Habits of Highly Effective People”, we’re looking at the second habit, “Begin with the end in mind.” In simple terms, this habit could be restated as, “Identify where you want to end up before you start doing anything.” Even simpler, habit two is about goal setting, but there’s more to it than just that.

Fundamental to whatever we do is knowing why we’re doing it. So, to be successful in habit two, we must also understand our inner core and our personal motivations. In previous columns from this space I’ve written about the six areas of learned motivation. Those can be easily reviewed by visiting ortoday.com and reading my columns from April through September of 2020. Learned motivators often intertwine with our inner-core drivers in life, what Covey calls our “center.” Covey suggests that to maintain integrity, we should be aware of our center. This is no small matter, because it’s from our center that we derive our sense of security and have a basis for guiding our decisions. Our centers also lead us to choose what knowledge we want to acquire, and also where WWW.ORTODAY.COM

we derive our sense of power. Different centers identified by Covey include money, work, possessions, pleasure, friends, enemies, church, self, spouse and family. One can also be principle centered. By way of example, I once had a client named Paul who used to be work centered. That meant Paul’s sense of security came from his job, and he made decisions based on how the outcome of those decisions affected his work. Paul often chose what to learn based on how it was going to help him at work, and his sense of power, or self-worth, came from being seen as someone who did his job well. Several years before I met Paul, he’d gotten laid off, and when that happened Paul’s world fell apart. He didn’t know he was work-centered, and therefore he didn’t understand why he went into a deep depression after getting laid off. The truth is that any center other than “principles” can be taken away from you and devastate your life. Think of someone ripping out the center core of the earth. It would be cataclysmic. Choosing to be principle centered not only creates more stability in life, it also enables us to have more integrity when setting and pursuing goals. That’s why Covey wants us to be aware of what drives us, and students of emotional

intelligence will recognize that this aligns with the starting block of emotional intelligence, which is “self-awareness.” Habit two (Begin with the end in mind) also involves the second block of emotional intelligence, “self-management.” In the next issue I will explore the nuts and bolts of goal setting along with some techniques for weekly planning. Between now and then, spend some time to re-familiarize yourself with your learned motivators. Also try to identify your center. The more self-aware you are in these areas, the easier it is to be better at self-management.

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 him through his website at MyWorkplaceExcellence.com or call his office at 208-375-7606.

February 2022 | OR TODAY

OUT OF THE OR pinboard nutrition

Don’t Go To Extremes By Kirsten serrano

hat do I mean by

W extremes? Look no further

than the extreme food tribes that have become incredibly popular. From the carnivore and keto diets on one end of the spectrum to veganism on the other, we are pulled in every direction. In decades past we had the zero sugar and zero fat extremes that wreaked havoc on our bodies and our food systems. So, what do we eat? Whether you are seeking better health or a sustainable life for you and the planet, you will not find it at the opposing ends of the dietary spectrum. In a lot of dietary circles, that’s not just controversial, but downright blasphemous. Let’s bust some myths by telling some truths. • Humans are designed to be omnivores. • Our bodies have requirements for proteins, fats and carbohydrates. • An all-plant approach is not going to save the planet. • Most of us need to eat more plants. • Good farming is the MOST important factor for feeding the

OR TODAY | February 2022

world sustainably and nourishing bodies. • Good farming involves plants and animals working symbiotically in a system. • There is no right way to eat for everyone. Wow. Writing that down almost feels like a declaration of war, but it is just facts. If that all makes sense to you, great. We are on the same page. Keep reading if you want some resources to further your understanding. If it does not make sense and you are really looking for answers that explain why our approach to food is often so misguided, keep reading. The resources are going to help you too. If you are saying, but I am not a nutrition expert or a farmer, do not worry. There are some excellent books that will explain what you need to know. One of the reasons extremes are so popular is that they are easy to explain. “Eat this, never that” is a great way to sell products and win followers. If that diet dogma often results in weight loss, well then you have hit the jackpot in the “wellness” world. So much of what we are told is boiled down to a slogan so here is what I call my universal truth. I call it universal because you already know it is true.

My universal truth is, “Our health, the quality of our food and the state of our planet are all interconnected.” So, what’s the thinking eater to do? Dig a little deeper. I promise you do not have to get a nutrition degree or buy a farm. I am continually asked for my top resources and where to start. These three books are it. They are where I started, what got me on my road to better health and ignited my passion for food literacy. They are excellent (and enjoyable) books for reading/ listening about getting smart about food (and impervious to marketing.) They are not about nutrition per se. They are about how our food system works which has everything to do with nutrition. These three books, which I have listed in the order I would read them, will explain how our food system works and where the problems are. • Animal, Vegetable, Miracle by Barbara Kingsolver • The Omnivore’s Dilemma: A Natural History of Four Meals by Michael Pollan • The Third Plate by Dan Barber My journey in understanding food compelled me to write my own book that breaks down what you really need to know about food WWW.ORTODAY.COM

into “digestible” lessons and then takes the next important step of guiding you in how to put it into practice. It covers everything from how we “broke” farming and why it matters to how to be a savvy shopper, outfit a kitchen and get meals on the table. My book “Eat to Your Advantage” is available for purchase online. However, you decide to approach it, I hope you do dig in and learn more about why our health, the quality of our food and the state of our planet are all interconnected and how you can apply that knowledge to your own life.

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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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February 2022 | OR TODAY

OUT OF THE OR recipe

Pesto Caprese Veal Cutlets

OUT OF THE OR recipe

INGREDIENTS: • 1 pound veal cutlets (about 2 ounces each)

Recipe

• 1 pint grape tomatoes, chopped

the

• 4 tablespoons prepared pesto • 1/2 cup flour

An Elegant Veal Meal to Impress Your Valentine

• 2 large eggs • 2 tablespoons whole or 2% milk • kosher salt, to taste • freshly ground black pepper, to taste • 1/2 cup seasoned breadcrumbs • 2 tablespoons butter, divided • 6 ounces regular or part-skim fresh mozzarella, sliced into 1/4-inch slices • 3 tablespoons toasted pine nuts (optional)

elebrating a special moment with your special someone this Valentine’s Day starts with a romantic meal. Cooking an elegant dish in your own kitchen offers a way to impress your valentine while enjoying the comforts of home.

Easy to make and ready in 30 minutes, these Pesto Caprese Veal Cutlets showcase the versatility and beauty of humanely

Pesto Caprese Veal Cutlets Funded by Beef Farmers and Ranchers Prep time: 15 minutes Cook time: 15 minutes Servings: 6

By Family Features

OR TODAY | February 2022

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Preheat oven to 350 F. Pound veal cutlets to 1/8-inch thickness.

In small bowl, toss tomatoes and pesto to mix well; set aside.

Place flour in shallow dish. In second shallow dish, beat eggs, milk, salt and pepper, to taste, until blended. Place breadcrumbs in third shallow dish. Dip each cutlet into flour then egg mixture then breadcrumbs to coat both sides.

raised veal in a flavor-packed recipe. One bite can transport you and your loved one from the kitchen to a garden in Italy. For added fun, try making homemade pesto to mix with grape tomatoes for a burst of flavor. Top with pine nuts and serve alongside a fresh salad or your favorite pasta for an unforgettably romantic meal. Find more recipes at Veal.org.

In large nonstick skillet over medium heat, heat 1 tablespoon butter until hot. Place half of cutlets in skillet; cook 3-5 minutes, or until golden brown and veal is cooked through, turning once. Remove cutlets; place on baking sheet.

Wipe out skillet with paper towel. Repeat with remaining butter and cutlets.

Place one slice cheese on each cutlet. Bake 3-5 minutes until cheese is melted. Transfer cutlets to plate and evenly top with tomato mixture; sprinkle with pine nuts, if desired.

February 2022 | OR TODAY

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fe, you’ll li in e v a h u o y t a h “If you look at w . If you look at what you always have moreyou’ll never have enough.” don’t have in life, – Oprah Winfrey

OR TODAY | February 2022

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By FAMILY FEATURES

n adjusting to the constraints of the pandemic, many Americans had to improvise where and how they work out. After months of adapting to a “gym anywhere” mentality and learning to accommodate more flexible workout schedules, this new fitness mindset is inspiring some larger trends for healthier living. “We’ve learned that wellness is not one-size fits all, and that it’s achieved by small habits like regular hydration that can really impact how you feel throughout the day,” said celebrity fitness trainer Harley Pasternak, MsC. “Collectively, nourishing both body and mind together as one makes holistic health a sustainable lifestyle.” Pasternak and the experts at Propel Fitness Water are forecasting five fitness and wellness trends to watch this year:

Accountability Buddies When gym closures ran rampant, folks leaned on others for inspiration to get moving, so it’s no surprise working out in pairs (or more) is a continued way to focus on fitness. Feelings of burnout may be common heading into 2022, so having a partner who gives you a healthy sense of camaraderie and competition can help push you to show up on days when you’d rather rest and stay committed to your goals. It also provides a sounding board when you need suggestions for nutritious recipes or fresh at-home cardio ideas.

Versatility in Gym Spaces and Schedules When a large segment of the workforce started working from home, the rituals of before- and after-work gym visits fell by the wayside. People grew more accustomed to improvising where they work out, whether it was their neighbor’s garage, their living room or a running path in the city. As exercisers are less beholden to studio or gym schedules, the “gym anywhere” mentality is a level of flexibility many are holding on to, even as

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pinboard

SHIFTING WELLNESS ATTITUDES SHAPE FITNESS TRENDS they ease back into more normal work routines.

Health in Small, Achievable Doses This trend is all about recognizing health transformations don’t happen overnight, and even modest steps can make a big difference in how you feel throughout the day. One example is paying more attention to your hydration. If you aren’t properly hydrated, few other things tend to go right either. Small habits like throwing Propel Powder Packs into your gym, work or school bag can make a difference. Filled with enough electrolytes to replace what is lost in sweat, they are handy for on-thego hydration and are easy to add to a water bottle.

Wellness Goals vs. Fitness Committing to overall wellness is more about lifestyle changes than numbers like weight loss or muscle mass. People embracing this trend are forgoing numeric goals based on performance in the gym or on the scale and instead emphasizing outcomes that affect life, nourishing both body and mind together as one. Fitness goals are an essential component, but so is supporting your mental health as well as being cognizant of what you’re putting into your body. When each piece is well taken care of, your body is better able to work like a well-oiled machine.

Low-Impact Workouts Walking treadmill challenges have gained virality on social media, marking the increasing popularity of workouts that are low impact yet effective. Getting moving is the key, even if it means taking your tempo down. You don’t need to do hours of HIIT every day to see results. In fact, less time- and energy-intensive workouts are easier to sustain and can often yield the same, or better, results. Find more hydration options and wellness tips at propelwater.com.

February 2022 | OR TODAY

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Healthmark Industries Company, Inc.………… 55 MD Technologies Inc.…………………………………………17 Ruhof Corporation…………………………………………… 2,3

FALL PREVENTION

ALCO Sales & Service Co.……………………………… 43 Encompass Group………………………………………………19

FLUID MANAGEMENT

MD Technologies Inc.…………………………………………17

AIV Inc.…………………………………………………………………15 ALCO Sales & Service Co.……………………………… 43 ALCO Sales & Service Co.……………………………… 43 Encompass Group………………………………………………19 Healthmark Industries Company, Inc.………… 55 MD Technologies Inc.…………………………………………17 Ruhof Corporation…………………………………………… 2,3

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

I.C. Medical, INC.………………………………………………… 4

STERILIZATION

Healthmark Industries Company, Inc.………… 55 MD Technologies Inc.…………………………………………17

INSTRUMENT STORAGE/TRANSPORT

SURGICAL

ONLINE RESOURCE

SURGICAL INSTRUMENT/ACCESSORIES

Ruhof Corporation…………………………………………… 2,3 OR Today Webinar Series…………………………………21

PATIENT MONITORING

AIV Inc.…………………………………………………………………15

PATIENT WARMING

Encompass Group………………………………………………19

REPROCESSING STATIONS

MD Technologies Inc.…………………………………………17 Ruhof Corporation…………………………………………… 2,3

SAFETY

The 1.06mm scope is designed to inspect internal channels of 1.1mm in diameter or larger, and the 1.9mm scope is designed to inspect internal channels of 2.0mm in diameter or larger.

BD……………………………………………………………………… 56

MD Technologies Inc.…………………………………………17

Scope Viewer Software: For Documentation of Photo & Video

Capture Images

Record Video

Easy-to-use Interface

Windows 10 Compatible

Reference Image Display

File Name Prefix Option

C Change Surgical………………………………………………13 Healthmark Industries Company, Inc.………… 55

TELEMETRY

AIV Inc.…………………………………………………………………15

TEMPERATURE MANAGEMENT

C Change Surgical………………………………………………13 Encompass Group………………………………………………19

WASTE MANAGEMENT

MD Technologies Inc.…………………………………………17

Healthmark Industries Company, Inc.………… 55

The Scope Viewer Software allows the user to easily capture and save photos and videos for future reference. An image reference window also allows the user to display a previously saved image to reference alongside of the live view of an item being inspected.

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For more of Healthmark’s optical inspection tools, including magnifiers, borescopes & more, visit

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BD ChloraPrep™ and BD PurPrep™ Patient Preoperative Skin Preparations with sterile solution

WITH AN EXCLUSIVE PORTFOLIO OF FULLY STERILE SKIN PREP APPLICATOR PRODUCTS. The landscape of healthcare is ever-evolving, especially when it comes to procedures and patient health. That’s why we are continuing to advance our portfolio of skin preparation applicator products. Our breakthrough sterilization process delivers the lowest risk of intrinsic contamination, providing you and your patients with peace of mind when undergoing procedures. BD ChloraPrep™ Patient Preoperative Skin Preparation with sterile solution is the only CHG/IPA sterile antiseptic solution product available in the U.S. When a CHG/IPA solution is not ideal, consider the PVP-I/IPA formulation of BD PurPrep™ Patient Preoperative Skin Preparation with sterile solution. Discover the unmatched confidence of full sterility in your skin prep. Discover the new BD.

Discover our fully sterile skin prep products at bd.com/sterilesolutionskinprep BD, the BD Logo, ChloraPrep and PurPrep are trademarks of Becton, Dickinson and Company or its affiliates. © 2020 BD. All rights reserved. 1020/5693