OR Today Magazine May 2022

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Career of Credentialing Professionals

Sterilization Services

CLABSIs

Marisa Streelman

MARKET ANALYSIS

CCI

CE ARTICLE

SPOTLIGHT ON

LIFE IN AND OUT OF THE OR

MAY 2022

NURSING

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S H O R TA G E

PA N D E M I C M A G N I F I E S S T R E S S , W O R K F O R C E I S S U E S

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OR TODAY | May 2022

contents features

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NURSING SHORTAGE The U.S. health care system is facing an acute nursing shortage that was only made worse by the COVID-19 pandemic.

This shortage is affecting every aspect of health care delivery, including perioperative services.

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A Globe Newswire report states that the

The goal of this educational program is to

Author explores the advice: “Don’t

global sterilization services market is

provide nurses in acute care settings with

prioritize your schedule; schedule your

projected to reach $5.5 billion by 2026.

information about the severity and causes

priorities.”

MARKET ANALYSIS

CE ARTICLE

EQ FACTOR

of central line-associated bloodstream infections and describe evidence-based interventions for the proper insertion and maintenance of central lines.

OR Today (Vol. 22, Issue #5) May 2022 is published monthly by MD Publishing, 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290.

POSTMASTER: See address changes to OR Today at 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290.

For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. © 2022

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OR TODAY | May 2022

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PUBLISHER

features

John M. Krieg

john@mdpublishing.com

VICE PRESIDENT

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Kristin Leavoy

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SPOTLIGHT ON Marisa Streelman

EDITOR John Wallace

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$25

ART DEPARTMENT

Gift C

Karlee Gower

ard

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Flatbread with Caramelized Onions, Bacon and Arugula

OR TODAY CONTEST

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RECIPE OF THE MONTH

DIGITAL SERVICES Cindy Galindo Kennedy Krieg

EVENTS

INDUSTRY INSIGHTS

Kristin Leavoy

09 News & Notes 18 HSPA: Keen Focus on Competencies Spurs Sterile Processing Quality, Safety 21 AAMI eXchange 2022: What SPD Professionals Shouldn’t Miss 22 ASCA: Make Sure Your ASC Is Performing at Its Best; Look to ASCA for Help 24 CCI: The Career Development of Credentialing Professionals 26 Webinar Addresses Forced Air Contamination Risk

ACCOUNTING Diane Costea

WEBINARS Jennifer Godwin

EDITORIAL BOARD

IN THE OR

Hank Balch, President & Founder,

28 M arket Analysis: Sterilization Services Market Continues Growth 29 Product Focus: Sterile Processing 32 CE Article: Cutting Out CLABSIs: Preventing Central Line-Associated Bloodstream Infections

Beyond Clean Vangie Dennis, MSN, RN, CNOR, CMLSO, Assistant Vice President, Perioperative Services with AnMed Health System Sharon A. McNamara, Perioperative Consultant,

OUT OF THE OR

44 Spotlight On: Marisa Streelman 46 Health 48 Fitness 50 EQ Factor 52 Nutrition 54 Recipe 56 Pinboard 57 AORN Scrapbook

OR Dx + Rx Solutions for Surgical Safety MD PUBLISHING | OR TODAY MAGAZINE 1015 Tyrone Rd., Ste. 120 Tyrone, GA 30290

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Elizabeth Vane, Health Science Teacher, Health Careers High School

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May 2022 | OR TODAY

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INDUSTRY INSIGHTS

news & notes

Bright Colors, Playful Characters, Bring Smiles While Easing Children’s Anxieties Healthmark Industries, Avanti Press and Fathead have together created themed areas featuring whimsical, universally relatable Avanti animal characters in designated locations at University of Michigan Health C.S. Mott Children’s Hospital in Ann Arbor, Michigan, where children might be more apprehensive for care, including the surgery waiting room area, along with some patient rooms and clinics. In addition, PPE themed scrub caps with these happy Avanti animal characters are being provided to staff in the children’s operating room areas to help create a fun distraction for children in preparation for surgery. Children will also be able to select animal character themed stickers which they can use as a badge of courage on patient gowns, IV bags, PICC line sleeves, casts and other areas. All images are being provided by Avanti Press, the Detroit-based publisher whose humorous characters are featured on greeting cards and numerous consumer goods sold nationwide and around the world.

Avanti’s bright, bold, photographic characters are featured in select areas of the hospital to help alleviate stress for children undergoing treatment.

Healthmark Industries envisioned this as a way to provide children with a fun, calming distraction within a hospital, doctor’s office or dentist’s office and would allow them to create a bond with hospital teams and focus on something other than their illness.

“Michigan based, Avanti Press was the perfect fit for this objective,” said Ralph Basile, Healthmark Industries vice president of marketing and regulatory affairs. “Their upbeat character humor connects with people young and old, from all walks of life. Avanti’s Licensing Agency, Lisa Marks Associates, saw the opportunity and helped bring us together to develop a meaningful program that would put a smile on patients’ faces.”

Healthmark Industries, having worked in the past with Fathead to create their bigger than life signage for hospital staff messaging, knew it was a natural that these three companies would select a Michigan-based children’s hospital (University of Michigan Health C.S. Mott Children’s Hospital). “To test this new concept to determine what resonates with pediatric patients and make them comfortable in an unfamiliar environment,” said Basile.

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“We currently design a variety of PPE for hospitals and have incorporated versions that allow staff (when permissible) to include individual images on scrub caps, which allows them to showcase their personality. We thought this was a natural opportunity to be able to extend this to health care workers interacting with children in environments that may help the child feel less apprehensive and more at ease in various health care environments they aren’t accustomed to,” said Basile.

“C.S. Mott Children’s Hospital is grateful for these generous donations from Healthmark Industries, Avanti Press and Fathead,” said Luanne Thomas Ewald, chief operating officer, C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital. “Hospitals can seem intimidating to children, and these joyful images in our halls and on the scrub caps of providers can offer some comfort and happiness for patients and families. During times of fear or uncertainty, something fun can make the difference.”

The businesses came together to develop this concept and approached the University of Michigan C.S. Mott Children’s Hospital to test this concept on a complimentary basis. Based upon feedback, the concept will be offered to other hospitals, physicians, dental and veterinary establishments to purchase for their health care environments.

“We are thrilled to support this project,” said Chip Owen, executive vice president for Avanti Press. “We hope our characters help to brighten the day for patients, family and staff at University of Michigan Health C.S. Mott Children’s Hospital.”

“We, at Fathead, truly believe that transforming spaces can bring warmth into an environment and create comforting spaces,” said Tony Saunders, owner & CEO of Fathead. “Our high-quality decals/decor dovetail well with Healthmark Industries mission and we are grateful to be a part of this empowering opportunity.

What better way to help ease the anxiety of a child in the hospital than creating larger than life designs that bring light into the hospital environment.”

The three companies will work with University of Michigan Health C.S. Mott Children’s Hospital to evaluate response and gain input from patients, as they move forward with this concept introducing it to other locations.

May 2022 | OR TODAY

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INDUSTRY INSIGHTS

news & notes

Gavel Passed at Successful AORN 2022 One order of business on the final day of the successful 2022 AORN Global Surgical Conference & Expo was the House of Delegates meeting.

At the March 23 House of Delegates meeting, Vangie Dennis, MSN, RN, CNOR, CMLSO, began her term as President of AORN for the 2022-2023 term. In a ceremonial passing of the president’s gavel, Holly Ervine, MSN, RN, NPD-BC, CNOR concluded her year as president of the association and transitioned to the role of advisor to the Nominating Committee.

Dennis is the assistant vice president for AnMed Health System located in Anderson County, South Carolina. In her address to the attendees, she congratulated all members who served before her for their vision and strategies that contributed to the value AORN brings to today’s members. She is looking forward to tackling future challenges that will call for invention, research, education and advocacy to advance surgery. Her theme for her term is, “No Limits,” her call to action for perioperative nurses and AORN to achieve their full potential.

The 2022-2023 election results are as follows: • President-elect: Elizabeth “Lizz” Pincus, MSN, MBA, RN, ACNS-BC, CNS-CP, CNOR • Vice President: Darlene Murdock, BSN, BA, RN, CNOR, CSSM • Secretary: Jamie Ridout, MSN, MBA, RN, CNOR, CASC, NEA-BC Elected to the 2022-2023 Board of Directors are: • Deborah Marie Ebert, MSN, RN, NEA-BC, CNOR, CCRN, CPAN, CAPA • Megan Nolan, MSN, RN, CNOR, CSSM • Rebecca Vortman, DNP, RN, CNOR Elected to the 2022-2023 Nominating Committee are: • Hung-Fu “Charlie” Lin, MSN, APRN, NP-C, CNOR • Daphny Peneza, MSN, RN, CNOR, CSSM • Olivia Jean Raymond, BSN, RN, CNOR For more information, visit AORN.org.

Next Generation of Surgical Robotics in Idaho Orthopedic surgeons at Northwest Specialty Hospital in Post Falls, Idaho, are among the first in the Pacific Northwest to access the next generation of surgical robotics. The VELYS Robotic-Assisted Solution indicated for use with the ATTUNE Knee System for total knee arthroplasty will soon be one of the few hospitals in the region and the only hospital in North Idaho to offer advanced knee replacement with the VELYS solution.

Total knee replacement is a common surgery, with approximately 900,000 primary knee replacements performed annually in the U.S. Orthopedic surgeons at Northwest Specialty Hospital now have a new option with the VELYS Robotic-Assisted Solution, a technology that helps surgeons perform a knee replacement with the use of data that’s tailored to each patient’s anatomy. This technology is designed to help ensure predictable results to improve outcomes, increase mobility and help patients recover faster. Additionally, the VELYS Robotic-Assisted Solution works in tandem with the ATTUNE Knee System, which is an innovative knee implant designed to work more closely with an individual patient’s anatomy. With these systems together, there is now an option for patients seeking the latest technology designed to provide digital precision in knee replacement.

This news follows an announcement by Northwest that the Blue Cross Blue Shield Association had selected Northwest Specialty Hospital as a Blue Distinction Center for Knee and Hip Replacement. This distinction recognizes their expertise in total knee and hip replacement surgeries, resulting in fewer patient complications and readmissions.

Rick Rasmussen, CEO of Northwest Specialty Hospital

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OR TODAY | May 2022

commented, “The orthopedic surgeons at Northwest Specialty Hospital are committed to bringing our patients the highest quality of care possible by introducing the next-generation of surgical robotics to advance the level of surgical care we offer.

This investment builds on the incredible work our team has done to become recognized by Blue Cross for safer knee and hip replacement surgeries.”

Designed by DePuy Synthes, the Orthopedics Company of Johnson & Johnson, the VELYS Robotic-Assisted Solution is a first-of-its-kind operating table-mounted solution that adapts to the surgeon’s workflow and utilizes advanced planning capabilities, proprietary technology, and a next-generation design to help surgeons accurately resect bones that align and position the implant relative to the soft-tissue during total knee replacement without the need for pre-operative imaging. The efficient and compact design integrates into any operating room and does so with a much smaller footprint, at less than half the size of other robotic-assisted solutions.

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INDUSTRY INSIGHTS

news & notes

ASTRA ® Automated Reprocessors

National Nurses Week Starts on May 6 OR Today joins in celebrating nurses and what they mean to health care across the globe. National Nurses Week begins each year on May 6 and ends on May 12, Florence Nightingale’s birthday. As of 1998, May 8 was designated as National Student Nurses Day, to be celebrated annually. And as of 2003, National School Nurse Day is celebrated on the Wednesday within National Nurses Week (May 6-12) each year.

International Nurses Day is celebrated around the world on May 12, the anniversary of Florence Nightingale’s birth.

FDA Clears Single-Use Sinus Debrider Olympus has announced FDA clearance for its Celeris single-use sinus debrider system with a full market availability in the near future.

The Celeris system contains the only single-use sinus debrider on the market and is indicated for cutting, coagulation, debriding and removal of thin bone and soft tissue in general ENT and sinus/ rhinology procedures. Specific procedures and applications would include turbinoplasty, polypectomy and endoscopic sinus surgery.

The system’s compact and portable design offers the flexibility of performing less invasive procedures in nearly any treatment room and is designed to eliminate the need to schedule costly OR time, while improving workflow. The single-use Celeris is also designed to eliminate reprocessing and maintenance costs normally associated with a full debrider system.

“While a full debrider system may be the right device in certain cases, the single-use Celeris debrider offers physicians another option for most of their routine procedures,” said Dana Currier, vice president and business unit leader ENT for Olympus Corp. of the Americas. “Its simple setup and single-use design allows physicians to treat patients in the more comfortable setting of an office treatment room rather than an OR. And it can help improve patient outcomes by offering a bipolar energy option to manage incidental bleeding.”

As with all electrosurgery instruments, inappropriate use can cause damage to tissue, both electrically and thermally.

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May 2022 | OR TODAY

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INDUSTRY INSIGHTS

news & notes

Vizient Contract Adds Touch Surgery Enterprise Medtronic plc has entered into a contract with Vizient to add Touch Surgery Enterprise to Vizient’s offerings.

The first AI-powered surgical video management and analytics platform for the operating room (OR), Touch Surgery Enterprise significantly simplifies the process of recording, analyzing and sharing surgical video – providing surgeons with a powerful new tool to improve performance and train others.

A fully integrated hardware and software system connected to the cloud, Touch Surgery Enterprise works easily with many laparoscopic and robotic scopes, enabling hospitals to take the first step to digitizing their OR while leveraging existing equipment.

“Touch Surgery Enterprise allows surgeons to use data to refine the way surgery is taught and executed, and we believe that will raise the standard of health care for all,” said George Murgatroyd, vice president and general manager, digital surgery within the surgical robotics business, which is part of the medical surgical portfolio of Medtronic. “This agreement with Vizient allows us to build on the strong interest we’re seeing globally, to support hospitals in the U.S. who are looking to harness the power of surgical video data and analysis.”

Touch Surgery Enterprise is part of Medtronic’s growing portfolio of artificial intelligence (AI) and surgical robotic solutions. It is compatible with the Hugo robotic-assisted surgery (RAS) system.

Vizient serves more than half the nation’s acute care providers, including academic medical centers, community hospitals, pediatric facilities and nonacute care providers.

Touch Surgery Enterprise is comprised of the DS1 computer and controller – surgical video recording hardware designed specifically for the OR. Applications of built-in AI include: • Automatic blurring of faces and protected information to ensure data privacy compliance before uploading surgical video to the AWS global cloud • Automatic segmentation of surgical video into key procedural steps for a growing library of procedures • Ability to benchmark a case against a bank of historical cases or make comparisons across departments All videos are accessed through the Touch Surgery App, which is free to download and home to academically validated and accredited simulations for mobile training on 200+ procedures in 17+ specialties. With 2.5 million active users, the app allows surgeons to prepare, practice and teach surgical procedures – anytime, anywhere.

“By simplifying the process to capture and analyze surgical video, Touch Surgery Enterprise gives surgical teams a powerful new tool to advance patient care,” said Megan Rosengarten, president of the surgical robotics business at Medtronic. “We’re excited about the impact it can make for customers today, as a solution for laparoscopic and robotic-assisted cases within their existing infrastructure, and for the possibility this technology creates in the future.”

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OR TODAY | May 2022

Guard Medical Announces FDA 510k Clearance for Additional Sizes of Novel NPseal Privately held company Guard Medical Inc. has announced FDA 510k clearance for additional sizes (10 and 15cm) of its negative pressure wound therapy (NPWT) dressing NPseal for the treatment of closed surgical incisions. NPseal is an easy-to-use and costeffective NPWT surgical dressing with an integrated pump that establishes and maintains negative pressure with just a few pinches.

“We’re excited to expand our NPseal portfolio, now with the 5, 10 and 15 cm sizes. NPseal can now be used on a large percentage of closed surgical incisions across multiple specialties. Receiving FDA clearance for the larger sizes is another significant milestone towards becoming the NPWT dressing of choice for the treatment of surgical incisions,” stated Machiel van der Leest, CEO of Guard Medical. “NPseal ease-of-use and cost effectiveness makes, for the first time, prophylactic use of NPWT for all eligible closed surgical incisions possible.”

NPWT has been shown to reduce surgical site infections (SSI) in a large number of peer reviewed articles but is in limited use due to its high cost and complexity. While being easy-to-use, NPseal delivers the same NPWT as current more expensive and complex NPWT devices.

For more information, visit guard-medical.com.

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INDUSTRY INSIGHTS

news & notes

PDI Healthcare Introduces Novel Disinfectants PDI, a leader in infection prevention products and solutions, has announced the dual launch of disinfectants to help infection prevention professionals in the fight against rising healthcareassociated infections (HAIs) as well as the ongoing battle against COVID-19. As part of a layered approach, the new products, Sani-24 Germicidal Disposable Wipe, Sani-HyPerCide Germicidal Disposable Wipe and Sani-HyPerCide Germicidal Spray, further support PDI’s commitment to help prevent infections and promote health and wellness.

Sani-24 wipe is the first and only EPA registered disinfectant that uses continuously active disinfectant (CAD), a revolutionary technology developed by a leader in antimicrobial solutions, Microban. CAD provides protection against a wide array of pathogenic organisms within a one-minute contact time, while leaving a protective layer of disinfectant on the surface as it dries.

This anti-microbial shield will continuously kill ESKAPE pathogens, which are responsible for over 40 percent of HAIs in the health care environment, as well as SARS-CoV-2, the virus that causes COVID-19, according to a news release.

“With constant challenges to control and prevent infections in health care settings, Sani-24 wipe is an important addition to our innovative portfolio of disinfectants that help maintain a clean and safe environment,” said Jake Watts, vice president, upstream marketing, PDI. “Given PDI’s long legacy of pioneering important infection prevention solutions, we are proud to offer health care facilities a solution that protects surfaces and equipment from recontamination around the clock.”

The release adds that Sani-HyPerCide disinfectant, available in wipe and spray formats, is a new, powerful and ready-to-use

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cleaner with a non-bleach, hydrogen peroxide formula effective against more than 20 HAI-causing microorganisms, including the highly contagious, difficult-to-eradicate pathogens, Clostridioides difficile (C. diff), Candida auris (C. auris), and norovirus, as well as SARS-CoV-2. Designed as an alternative to bleach disinfectants, the Sani-HyPerCide portfolio provides easy-to-use and efficient one-step cleaning and disinfecting used for daily, terminal and outbreak cleaning, compatible with most materials and surfaces, and requires no mixing or diluting, the release states.

“Its innovative formulation and multi-purpose usability enhances overall time efficiency and reduces risk of uniform discoloration as seen with bleach products,” the release states.

Recently, hospital and health care settings have experienced an alarming rise in serious and emerging pathogens. In fact, a report by the Centers for Disease Control and Prevention (CDC) showed that, after years of decline, U.S. hospitals saw significant increases in HAIs in 2020, largely as a result of the COVID-19 pandemic. The CDC has also deemed superbugs such as C. diff and C. auris as urgent threats to the U.S health care system due to their extremely contagious nature, high mortality rate and resistance to treatment.

“Today’s vulnerable health care environment has prompted an urgent need to strengthen infection prevention programs to better safeguard patients and staff,” said Watts. “Multiple layers of defense, including effective and easy-to-use disinfectants, will continue to be key to helping prevent infections, save costs and improve care.”

For more information, visit pdihc.com/dual-innovation.

May 2022 | OR TODAY

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INDUSTRY INSIGHTS

news & notes

Vasospasm Treatment Receives Breakthrough Device Designation Rapid Medical, a developer of advanced neurovascular devices, has announced FDA breakthrough designation for its Comaneci embolization assist device to facilitate the treatment of cerebral vasospasm following hemorrhagic stroke. Vasospasm is a major complication and cause of morbidity. The FDA’s Breakthrough Device Program is designed to give patients more timely access to novel technologies, like Comaneci, that provide more effective treatments for life-threatening or irreversibly debilitating human diseases and conditions.

“We just need better solutions for patients – no single treatment has been shown to be uniformly safe and effective in treating symptomatic vasospasm,” comments Brian Jankowitz, MD, a neurosurgeon at the University of Pennsylvania. “Comaneci is the first device to provide combination therapy to the brain with an adjustable diameter/ radial force that may lower the risk of vessel injury.”

“Comaneci, available in Europe for vasospasm intervention, is showing promising results. In a 30-patient multi-center retrospective analysis, 97% of patients showed an increase in vessel opening of at least 25%, with 80% of patients showing an increase of 50% or more. Additionally, over 10,000 procedures have been performed world-wide utilizing Comaneci to assist in the coil embolization of wide-neck intracranial aneurysms. Comaneci’s adjustable diameter, low-delivery profile and excellent visibility have drawn physicians around the globe to demand Comaneci. As a temporary device, it offers a treatment modality that may prevent the need for permanent devices implanted in the brain,” according to a news release.

For more information, visit rapid-medical.com.

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OR TODAY | May 2022

RSIP Vision Presents New Tool for TSA Planning RSIP Vision has announced a new tool for total shoulder arthroplasty (TSA) planning. This tool performs segmentation of the shoulder bones from shoulder MRI scan, which is usually performed in shoulder health care. The segmentation output undergoes super-resolution enhancement to overcome inherent MRI resolution limitations. The end-result is a high-quality, 3D model of the shoulder bones, which allows exceptional planning for TSA, without the need for a CT scan for planning. This new vendor-neutral technology is available to third-party MRI manufacturers and viewer solutions, allowing an accurate and radiation-free method for TSA planning.

“Shoulder MRI scans are common in shoulder pain management health care, usually for soft tissue analysis,” said Ron Soferman, CEO at RSIP Vision. “Deep learning (DL) algorithms can be developed for accurate segmentation of the shoulder bones. Neural networks are trained to process the resulting segmentation into a CT-grade segmentation, improving the original MRI resolution. Further down the line this tool can be altered to segment soft tissue, as well as other anatomies. This tool improves shoulder health care as it removes the need for a CT scan and its accompanying radiation and cost.”

Shoulder injuries often require a diagnostic MRI scan, mainly to rule out soft-tissue damage. When approaching TSA, current practice requires a CT scan for procedural planning as CT resolution is superior to that of MRI. However, an additional CT scan involves exposing the patient to harmful radiation, as well as additional health care expenses.

RSIP Vision’s new tool utilizes the shoulder MRI scan, without compromising on resolution quality. It automatically segments the humerus and scapula from the scan. The segmentation output goes through another neural network, trained to upgrade segmentation resolution, thus producing a super-resolution model despite the original scan limitations. This output is as-good as CT-based models, without the need for an additional scan, and can be used for procedural planning.

“As a physician, you want to reduce radiation exposure to your patient,” said Dr. Shai Factor, orthopedic surgeon at Tel-Aviv Medical Center. “This new tool by RSIP Vision will utilize existing shoulder MRI scans, which we use routinely to demonstrate associated soft tissue pathologies, and will offer a radiation-free alternative to patients prior to shoulder arthroplasty, without compromising the 3D model’s quality.”

For more information, visit rsipvision.com

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INDUSTRY INSIGHTS

Anesthesia Touch Surpasses 1,000 Hospital Installations

news & notes

Plexus Technology Group LLC (Plexus TG), a provider of anesexploration to a sophisticated and integrated platform that clients thesia information management systems (AIMS), announces that can continue to leverage to differentiate themselves in their marits AIMS, Anesthesia Touch, has reached a critical milestone by kets. The financial burdens of deploying an anesthesia informabeing deployed into over 1,000 hospital systems nationwide and tion management system are no longer an issue when practices over two million surgical cases. work with Plexus TG’s Anesthesia Touch, integrated with ABC Plexus TG’s Anesthesia Touch is an automated medical and their F1RSTAnesthesia billing platform.” record-keeping system that streamlines the capture of real-time “The relationship of our technology products creates a unique anesthesia data throughout the perioperative process, enabling synergy in the anesthesia marketplace,” remarks Tony Mira, CEO Wednesday, Thursday, Friday, Saturday anesthesia providers to deliver safe, effective care to patients. Built and president of ABC and Plexus TG. “Our commitment to our June 1-4, 2022 for anesthesia providers, anesthesia physician groups,Dallas ambulatory clients extends far beyond a billing contract and this milestone Marriott City Center surgery centers, hospitals and office-based surgery settings, Anesshows our commitment to our clients’ success in the entire periThe best of the field converging in thesia Touch’s plug-and-play technology is built to go anywhere Dallas Texas operative process. Integration of Anesthesia Touch with F1RSTinfo@scrubball.org and integrates seamlessly into Anesthesia Anesthesia is the most advanced data capture, data analytics tool Healthcare Conference & GalaBusiness Consultants’ www.scrubball.org (ABC’s) F1RSTAnesthesia billing platform. that gives our clients the advantage in managing staffing and OR “We are incredibly proud of this achievement and with the utilization, as well as payor contract negotiation.”

"Toour do clients,” what nobody else greater expansion of the technology infrastructure for will do, a way that nobody comments Bryan Sullivan, COO of Plexus TG. “Ourelse reach For information, visit Plexustg.com. canisdo, in spite of more all we through; that is to unparalleled. We have navigated from the early days of go AIMS be a nurse." -Rawsi Williams-

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INDUSTRY INSIGHTS

news & notes

Getinge Launches Modular Room System Getinge is launching the new and extended modular room system Getinge IN2 – an intelligent solution for creating interconnected, sustainable and efficient workplaces in hospital departments around the world.

“Getinge IN2, the successor to our Variop and Variward systems, is designed intuitively to evolve with cutting-edge technologies in the operating room (OR), intensive care unit (ICU) and central sterile supply departments (CSSD). It complements nicely our existing range of equipment to provide complete, integrated turnkey solutions,” says Philippe Rocher, president at Getinge South Asia Pacific.

Apart from creating a functional and safe work environment, the new modular room system is a game changer in other aspects.

“Projects using prefabricated Getinge IN2 elements can be completed 40 percent faster than projects using conventional construction materials. This keeps timelines on track, on budget, with less downtime, noise, dust and disruption,” Philippe explains.

The solution consists of a substructure, wall and

16

OR TODAY | May 2022

ceiling elements, doors and built-in elements. These are sealed down to the substructure to make disinfection easier; which helps prevent cross-contamination and health care acquired infections.

The modular components are designed to be assembled and disassembled without special tools. A wide range of options and interchangeable elements are available to easily build or remodel hospital departments based on specific needs.

“The modern design allows for elements to be reused and repurposed, reducing carbon footprint and maximizing the return on investment,” says Philippe. “In addition to stainless steel and glass, we have added new alternative surface materials, such as high-pressure laminate (HPL) and solid surface.”

“We have also incorporated appealing design elements to create a more pleasant hospital environment that can ease stress and uplift moods, thus improving efficiency.

In short, we are confident that Getinge IN2 will be the key to building the ideal health care environment of tomorrow,” he adds.

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ProFormance™ Cleaning Verification Clearly Visible, Easy to Interpret, Objective Tests of Cleaning Methods

SonoCheck™ When the ultrasonic cleaner is supplying sufficient energy and condi�ons are correct, SonoCheck™ will change color. Problems such as insufficient energy, overloading, water level, improper temperature and degassing will increase the �me needed for the color change. In the case of major problems, the SonoCheck™ will not change color at all.

TOSI® Reveal the hidden areas of instruments with the TOSI® washer test, the easy to use blood soil device that directly correlates to the cleaning challenge of surgical instruments. TOSI® is the first device to provide a consistent, repeatable, and reliable method for evalua�ng the cleaning effec�veness of the automated instrument washer.

LumCheck™ The LumCheck™ is designed as an independent check on the cleaning performance of pulse-flow lumen washers. Embedded on the stainless steel plate is a specially formulated blood soil which includes the toughest components of blood to clean.

FlexiCheck™ This kit simulates a flexible endoscope channel to challenge the cleaning efficiency of endoscope washers with channel irriga�on apparatus. A clear flexible tube is a�ached to a lumen device with a test coupon placed inside; the en�re device is hooked up to the irriga�on port of the endoscope washer.

HemoCheck™/ProChek-II™ Go beyond what you can see with all-in-one detec�on kits for blood or protein residue. HemoCheck™ is simple to interpret and indicates blood residue down to 0.1μg. The ProChek-II™ measures for residual protein on surfaces down to 0.1μg.

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INDUSTRY INSIGHTS HSPA

Keen Focus on Competencies Spurs SP Quality, Safety

By Tony Thurmond, CRCST, CIS, CHL, FCS ompetency is a term that relates to performance improvement, and professionals are expected to attain and cultivate it through experience and a desire to learn, grow and advance in their knowledge and skillsets. In the sterile processing (SP) environment, it’s important to examine how competencies are valued and applied. Are they viewed as a necessary evil or do SP professionals embrace the opportunities competencies can provide?

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ANSI/AAMI ST79, Section 4.2.2, states that “the responsibility of sterile processing should be assigned to qualified individuals who have demonstrated competence in all aspects of sterile processing.” Qualifications for SP professionals include demonstrated knowledge of and documented competencies in the tasks they perform, and a working knowledge of the work environment. Documentation is critical because there must be evidence that proper training and demonstration of that training took place. Surveyors will ask to see employees’ orientation checklists and the documented competencies for each employee.

Tap power of checklists Thorough competency checklists must be created and maintained for each of the following areas of the SP department (SPD): • Decontamination: Competency 18

OR TODAY | May 2022

must be shown in instrument sorting, disassembly/reassembly, manual and mechanical cleaning methods, microbicidal processes, equipment operation, standard- and transmission-based precautions, and engineering and work practice controls.

• Instrumentation: SP professionals must know the names and descriptions of instruments in the organization’s inventory as well as the demonstrated inspection points of each device. Other competencies include proper preparation and packaging methods for sterilization.

• Sterilization/High-level Disinfection (HLD): Competencies should cover all sterilization practices and principles, including steam, lowtemperature, ethylene oxide and HLD processes.

• Worker Safety and Environmental Safety: SP professionals should understand and be able to demonstrate how to properly handle emergent situations, environmental hazards and other patient safety situations.

More competencies can be developed for specific equipment and instrumentation (to include proper cleaning techniques, sterilization and maintenance of each). Note: A completed competency does not ensure a technician is competent, much the same way that holding certification does not ensure an individual’s competency. The proper skills learned and used effectively in day-to-day operations are what make for a competent technician. Some technicians can demonstrate the correct way of perform-

ing a task during a competency review, but then return to their bad habits after the review. Still, a competency checklist can benefit the department and facility in numerous ways, as the following paragraphs will demonstrate.

When developing a competency checklist, equipment and departmental design will dictate the processes and workflow necessary to be completed.

First, an orientation checklist must be developed and implemented for new SP employees. New team members should work with a competent technician who is willing to train and has the skills required to properly onboard the new employee.

This orientation checklist is typically completed after 90 days of employment to verify the skills learned and the likelihood of the department continuing with the individual’s employment.

If the new employee demonstrates they have retained the training information provided and have the desire to continue to learn and broaden their skills, this growth should be documented by the SP leadership during the 90 days. If areas of weakness surface or it is determined certain information was not retained, the supervisor must review the training process and its effectiveness. The supervisor may need to review the preceptor or trainer to determine whether the proper information was given and whether certain aspects of the training process could be improved.

If no improvement is needed in the training process and the preceptor is providing proper, effective training, it must then be determined whether the WWW.ORTODAY.COM

INDUSTRY INSIGHTS HSPA

new hire can be successfully trained and prepared for their role. Everyone learns at their own pace; however, the individual must demonstrate the desire to learn and do their best if they are to move past their 90-day review and continue to grow into a strong, proficient SP professional.

It is recommended that new employees both verbalize and demonstrate the task(s) being evaluated.

Competency checklists must be written in the proper order of the process or workflow for the desired knowledge and skills being reviewed − and each item to be reviewed must be thoroughly understood and/or demonstrated. The checklist should indicate whether the demonstration is verbal or demonstrated, and it must be marked as “satisfactory” or “unsatisfactory” by the SP supervisor or manager. Each task/line item must be initialed by the person reviewing it to document that a thorough review was performed. Checklists should also

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include an area for comments (which can include suggested training or positive comments for technicians who demonstrated success and aptitude with a particular task).

The checklists must be reviewed at least once every six months to determine areas in need of improvement. Managers should ensure the checklist is current, taking into consideration any changes to equipment or internal processes, and whether any standards updates occurred that could require a change to current practices. If more errors have been identified in certain areas or for certain processes, an impromptu competency review may be necessary. Competency reviews for each technician must be reviewed by a competent technician, educator or manager who has also demonstrated working knowledge and expertise of the area being reviewed/assessed. The checklist must be signed by both the evaluator and the individual being evaluated, and

the competency should be placed in the employee’s file.

Conclusion Competency checklists are considered a requirement in the SPD and other health care departments because they allow departmental leaders to assess areas in need of improvement and gauge employees’ consistent adherence to best practices. Checklists can also lead to more standardization regarding how tasks and processes are performed, which can further lead to performance improvement and error reduction.

– Tony Thurmond, CRCST, CIS, CHL, FCS, serves as central service manager for Dayton Children’s Hospital. He is an HSPA past-president who currently serves as a director on the HSPA Board of Directors.

He earned his HSPA Fellowship in 2021.

May 2022 | OR TODAY

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INDUSTRY INSIGHTS AAMI

AAMI eXchange 2022: What SPD Professionals Shouldn’t Miss he annual health technology networking event, AAMI eXchange, is returning as an in-person meeting in San Antonio, Texas on June 3-6. This year, a dedicated track of sessions will help sterile processing professionals and leadership catch up on changes in regulation, best practices and strategies for improving their hospital, clinic or industry department.

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Considering ANSI/AAMI ST91:2021 The latest updates made to ANSI/ AAMI ST91:2021, Flexible and semirigid endoscope processing in health care facilities, addresses new technologies as well as concerns about medical device cleanliness and patient safety.

The new update reflects the consensus of industry, clinicians and sterilization professionals from around the world.

However, it may also represent significant changes for many sterile processing departments.

The Saturday, June 4 sterilization track wraps up just before the day’s main stage presentation with “Equipment Qualification in Sterile Processing: Quality Management From Day One” at 9:15 to 10:15 a.m. This session will delve into how ST91 provides a performance baseline for documenting what equipment is actually capable of after installation in a facility.

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“In this talk, I will discuss installation qualification, operational qualification and performance qualification, and requalification to make sure performance is maintained over time,” said presenter Jonathan Wilder, Ph.D., Quality Processing Resource Group LLC. Does your department do a lot of endoscope reprocessing? At 2 p.m. on June 5, Jill Morgan of Emory University Hospital will be joined by Garland-Rhea Grisby Sr., the Kaiser Permanente endoscope service manager who co-led the ST91 update, to outline the importance of having staff dedicated to endoscopes and their associated guidance.

“When a patient undergoes surgery, they want a highly skilled and trained physician performing the procedure.

The same can be said of those who will process the endoscopes and probes,” they explained. “This session will demonstrate the consequences of improper training and lack of processing opportunities and the benefits of dedicated staff.”

Future-Facing Sessions On Saturday, June 4, tech savvy and forward-looking professionals will start their morning with a special 7:15 a.m. session, “Reprocessing of Robotic Surgery and Reusable Instruments.” Stuart White, MIDSc (Chtd), of CMR Surgical will introduce minimal access surgery and robotic-assisted surgery and detail the differences between standard and robotic surgical instruments. The presentation will delve into the challenges

of reprocessing robotic surgical instruments including design considerations, requirements and standards, validations steps and how to ensure patient safety throughout the process.

Directly afterwards, department leaders can learn how their sterile processing department “measures up” to industry expectations. In an 8 a.m. education session, attendees can learn about the strategies and practical quality management tools that can help identify a successful team’s next opportunity for improvement.

Modalities and More A common theme for every eXchange, sterilization professionals will also be treated to multiple education sessions exploring the latest techniques and best practices associated with sterile processing modalities.

Sessions include a look at uncommon steam sterilization methods, discussing chlorine dioxide versus ethylene oxide, methods for attacking special pathogens and innovative research on the effects repetitive handling has on a sterile package in a health care setting.

Of note, the KiiP Movement dedicated to innovation in sterile packaging will also be outlining a number of special projects, accomplishments and next steps for industry collaboration on June 5 at 4:15 p.m.

For more information, visit www.aami.org/conferences/event/exchange-2022-education-sessions.

May 2022 | OR TODAY

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INDUSTRY INSIGHTS ASCA

Make Sure Your ASC Is Performing at Its Best; Look to ASCA for Help

By Bill Prentice ay is a good month for ASCs to take stock of their overall operations and consider any adjustments they might want to make to be certain they end the year stronger than they started it. ASCA offers a range of resources to help. All are developed specifically for ASCs.

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Benchmarking For ASCs that want to determine how their facility is performing in comparison to others in their area or across the country, ASCA’s Clinical and Operational Benchmarking Survey is a good place to start.

This survey collects data on volume, quality, operations, outcomes, complications, staffing and finance.

Three optional specialty tracks also allow ASCs to compare data on total joint, complex spine and ophthalmology procedures. Since 2020, the survey has been recognized as meeting the Accreditation Association for Ambulatory Health Care’s (AAAHC) Advanced Orthopaedic Certification requirements as a nationally recognized specialty-specific data repository.

Participants complete the survey four times a year and have year-round access to the reports. Q1 reports for the program are available May 15.

ASCs that have not subscribed to the 2022 survey can still sign up. Although 22

OR TODAY | May 2022

they will not be able to submit Q1 data, they will be able to see others’ reports for the full year.

Regulatory Compliance As always, as the leading advocate for ASCs of every specialty in Washington, D.C., ASCA is in a unique position to provide the information and resources ASCs need to comply with all the new regulations Medicare and others introduce each year.

We offer a mix of publicly available and members-only resources that include our Advancing Surgical Care Podcast, online resources, ASC Focus magazine, webinars and in-person and virtual events.

So far this year, in response to requests from our members and others, we have put a lot of time into compiling and sharing the information ASCs need to comply with the new billing and patient notification requirements set in the No Surprises Act. We have also developed resources to help ASCs meet Medicare’s 2022 quality reporting requirements, including the program’s new vaccine quality reporting measure ASC-20: COVID-19 Vaccination Coverage Among HCP.

For Staff ASCA continues to offer a broad range of opportunities for ASC staff to get the education they need to take their

skills to the next level and provide the highest quality care. From an online training series that individuals can access and study at their convenience on their home or office computer to our yearlong webinar series and other on-demand events, these programs feature top experts in ASC management in every operational area in an ASC. Several offer valuable information for candidates preparing for the Certified Administrator Surgery Center (CASC) and Certified Ambulatory Infection Preventionist (CAIP) credentialing exams.

This year, one program we are especially proud of is a new mentoring program we developed to help new and aspiring ASC administrators master the multi-faceted skillset needed to manage an ASC. Through this ASC Administrator Development Program, we connect mentors, who are experienced ASC administrators, with mentees, who are ASC administrators who have just stepped into that role or other ASC staff hoping to become an ASC administrator one day. Throughout the year the mentees participate in specialized educational programs and meet periodically with their mentors to discuss a prescribed curriculum as well as other ASC management questions they bring to those meetings personally.

ASCA designed this program in response to concerns expressed by our members about the growing numWWW.ORTODAY.COM

INDUSTRY INSIGHTS ASCA

ber of ASC administrator positions that are becoming available at the same time we are hearing that these vacancies are becoming increasingly difficult to fill. In its first year, the program is on track to enroll more than 30 mentees and more than 20 mentors. It is too late to sign up for this year’s program, but I encourage anyone with an interest in this opportunity to consider enrolling next year.

For Physicians ASCA’s ongoing advocacy efforts make the needs of ASC physicians a priority, whether those physicians are owners of a center or not.

To keep these physicians informed about the legislative, regulatory and business developments that affect the care they provide in the ASC

setting, ASCA now offers a free quarterly one-pager we call the “ASC Physician Brief.” Mindful of the many demands on every physician’s time, the news is distilled down to its essence and presented in bite-size pieces that can be absorbed quickly.

Readers who want to delve deeper are invited to consult the source material provided.

Also for physicians, we continue to invite other ASC physicians to talk about ways they have expanded their ASCs, overcome challenges or pioneered new territory in the ASC setting.

We share these stories in our podcast, our magazine and our educational programs throughout the year.

information ASCA offers you is for your ASC to be a member of ASCA. ASCA membership dues also support the critical advocacy work we do on behalf of ASCs. Without our members, that work would not be possible, and ASCs would not be involved in the critical regulatory and policymaking conversations taking place today that will determine what role ASCs will play in the U.S. health care system in the future.

If your ASC is not a member, or if you are not sure if your ASC is a member, please contact Mykal Cox. He can help you become a member and gain access to all the specialized tools and resources ASCA has developed exclusively for ASCs.

Membership

– Bill Prentice is the chief executive officer of the Ambulatory Surgery Center Association (ASCA).

Of course, the best way to be sure you have access to all the resources and

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INDUSTRY INSIGHTS CCI

The Career Development of Credentialing Professionals

By James X. Stobinski ften in these columns I provide updates on the credentialing work done by the Competency and Credentialing Institute (CCI) and our certifications. This month, I would like to share information about credentialing, but I will not be speaking to certifications held by perioperative nurses nor about new programs being developed by CCI.

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In the first four decades that CCI has been in existence we had customer service representatives who were the primary point of contact for our applicants and certificants. These representatives worked closely with a small group of nurses employed by CCI, but the focus was on the administrative tasks needed to earn and maintain credentials such as registering for certification examinations. The customer service team did not have a career path as do many perioperative nurses.

CCI is a member of the Institute for Credentialing Excellence (ICE) which is, “… a professional membership association that provides education, networking and other resources for organizations and individuals who work in the credentialing industry.”(ICE, a) In 2008, ICE began the formalized study of the tasks performed by staff, such as the customer service representatives at CCI, working in the credentialing industry.

It was established that the work of credentialing could be delineated and that there was a distinct body of knowledge.

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ICE began developing training courses for these staff and in 2018 work began on developing a certification process for those working in the credentialing industry. In a parallel effort ,CCI was also re-thinking the role of the staff who worked with our certificants.

Through committee work with ICE, CCI staff had a small role in defining a career path for credentialing workers. An ICE task force identified, “… six career pathways with associated general and technical competencies that credentialing professionals can use to identify and guide their desired journey.”(ICE, b) Among these six roles are credentialing associate or coordinator and director. CCI, in its reorganization efforts, had established these roles which were now validated by the ICE task force. The CCI credentialing team, which now numbers five staff members, can now align with the ICE findings and further formalize their career paths. As a first part of that journey, all CCI credentialing team members have completed the Certificate for Credentialing Specialist Program from ICE. The collective efforts of the ICE committees and task forces culminated in the ICE-CCP (Certified Credentialing Professional) certification program which launched in late 2021. A CCI staff member was in the first group to be granted the credential. Using the career development resources promulgated

by ICE, we have now charted a career development path for the CCI credentialing team. The path we envision

is similar to the clinical ladders which are so familiar to perioperative nurses.

Upon becoming eligible, each of the CCI credentialing team members will be reimbursed the fees for the ICE-CPP certification examination.

The CCI staff has a long history of engagement and volunteer service in the credentialing industry to include work with our accreditation and membership boards. The credentialing team has now joined the CCI nursing staff in that service. This volunteer service gives us a seat at the table as policy and accreditation standards are shaped.

Ultimately, planned career development and engagement in the credentialing industry will enhance the quality of service offered to our perioperative nurses. The senior leadership of CCI and our board of directors are grateful for the hard work and dedication of our credentialing team and we are delighted to provide the resources to facilitate this career progression.

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

References Institute for Credentialing Excellence. (n.d., a).

About us. Accessed March 1, 2022 at: https:// www.credentialingexcellence.org/About Institute for Credentialing Excellence. (n.d., b). Credentialing Associate and Coordinator Career Pathway. Accessed February 27, 2022 at: https://www.credentialingexcellence.org/MyCareer/Career-Pathways/credentialing

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INDUSTRY INSIGHTS webinar

WEBINAR SERIES

Webinar Addresses Forced Air Contamination Risk Staff report he OR Today webinar “Forced Air Contamination Risk in the OR” was eligible for 1 CE credit. The presentation was sponsored by Encompass Group. OR Today has been approved and is licensed to be a continuing education provider with the California Board of Registered Nurses, License #16623.

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In this webinar, Victor Lange, director, infection prevention and healthcare risk management/epidemiology of Alta Hospital Systems explained the infection and crosscontamination risk associated with use of forced-air warming on patients in the OR. He discussed ways OR professionals can contribute to improved facility risk review and improved patient-warming and infection-prevention protocols.

He also explored new findings on patient warming.

During a question-and-answer session, Lange provided additional insights. One question was, “Are there specific areas of the forced air 26

OR TODAY | May 2022

warming devices that contain higher concentrations of microorganism contamination or colonization?”

“As I mentioned before, the forced air warming units – as well as most any devices – have many complicated components, or parts in this case. We were identifying pathogens on the hose connections to the machines also on the hoses themselves on the inside of the hoses as well as improperly maintained filters on the devices themselves. So many nooks and crannies are present on a lot of these devices and all it takes is just the improper processing of any device or any component to lead to contamination. We need something that’s able to be disposed of. Even if you have components that are disposable, you need to make sure that the reusable components of the device are processed accordingly.

Again, the highest correlation was attributed to hoses, hose connections of the device itself through which the warm air was blowing and subsequently blowing through the device and blowing out around the OR suite,” Lange said.

He was also asked if there is a way to ensure that the forced air warming device is completely disinfected internally and externally?

Lange replied that it is very, very difficult to ensure 100% disinfection of virtually any of these devices unless there is a way to send them through a sterilizer because there are areas of the device that can’t be disinfected to the highest potential unless they are subjected to some sort of gas or a technique where they are immersed or completely saturated with a disinfectant for a specified period of time.

“In summary, it is very difficult to guarantee the complete disinfection of such devices,” he added.

The webinar is available for on-demand viewing at ORTodayWebinars.live.

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market analysis

Sterilization Services Market Continues Growth Staff report lobe Newswire reports that Reportlinker.com has released a research on the sterilization services market. The report states that the global sterilization services market is projected to reach $5.5 billion by 2026 from an estimated $4.1 billion in 2021.

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The introduction of mandates by government and regulatory bodies in the health care industry is the primary reason for the market witnessing significant growth.

The growth of the sterilization services market can largely be attributed to factors such as the high incidence of hospitalacquired infections; the increasing number of surgical procedures; the growing focus on food sterilization; and the increasing outsourcing of sterilization services among pharmaceutical companies, hospitals and medical device manufacturers. In addition, the growing medical device and pharmaceutical companies in emerging economies, increasing use of E-beam sterilization, reintroduction of ethylene oxide sterilization and the growing health care industry and outsourcing of operation to emerging countries are expected to offer high-growth opportunities for market players during the forecast period.

With the surge in COVID-19 cases, there is an increasing focus on personal hygiene and the production of medical nonwovens and single-use products, such 28

OR TODAY | May 2022

as face masks and gloves. This is further expected to drive the growth of the sterilization services market in the coming years.

On the other hand, concerns regarding the safety of reprocessed instruments are expected to limit market growth to some extent in the coming years. This, along with the end-user noncompliance with sterilization standards, is expected to restrain the growth of this market.

The ethylene oxide (EtO) sterilization segment accounted for the largest share of the sterilization services market in 2020. This segment’s large share can be attributed to its extensive usage in various applications, including medical device sterilization, food testing, pharmaceutical sterilization, and sterilization and disinfection in the life sciences industry.

In 2020, the contract sterilization services segment accounted for the largest share and is also expected to grow at the highest CAGR during the forecast period. This can be attributed to the growing preference for contract sterilization by medical device companies and the increasing outsourcing of sterile processing by hospitals to specialized third-party vendors to reduce in-house costs related to sterilization.

In 2020, the off-site sterilization services segment accounted for a larger share of the sterilization services market.

The limited availability of space in in-house sterile processing departments,

better efficiency of contract sterilization process than in-house sterilization, greater output with less financial risk, and the cost reduction benefits offered by off-site sterilization services are key factors supporting the segment’s growth.

The medical device company segment is expected to grow at the highest CAGR during the forecast period.

Growth in this segment is majorly attributed to the rising prevalence of HAIs, increasing adoption of single-use medical devices, the growing medical device industry and the rising number of surgical procedures worldwide.

In 2020, North America accounted for the largest share of the sterilization services market, followed by Europe, the Asia Pacific, Latin America, and the Middle East & Africa. The region’s large share can be attributed to the growing demand for and adoption of sterilization services due to the rising focus on healthy lifestyles and disease prevention among consumers.

A surge in the geriatric population in the coming years and the subsequent increase in the prevalence of chronic diseases, the need for sterilization services to minimize the prevalence of HAIs, and implementation of favorable government initiatives and stringent regulations for sterilization services are also expected to propel the sterilization services market in North America.

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product focus

TBJ Inc.

SurgiSonic 1211X TBJ’s SurgiSonic 1211X features a patented dual hook up method for pre-cleaning da Vinci instruments utilizing a filtered, independent flushing system combined with ultrasonic action. The unit is independently tested for cleaning effectiveness and exceeded AAMI TIR 30. Three instruments can be pre-cleaned simultaneously. The system is also ideal for other types of non-robotic submersible tubular instruments as six instruments can be pre-cleaned simultaneously. Available in an economical counter top unit or floor standing unit with automatic water filling and automatic drain control.

For more information, visit tbjinc.com.

STERIS IMS

VerifEye Insulation Tester Mono-polar and bi-polar surgical instruments insulation integrity testing is critical for safe device handling/use and risk mitigation. Visual inspection is not enough to ensure that insulation failures are detected before the devices are used in the OR. STERIS IMS has a solution that easily allows a facility to test the insulation on these items at the point of processing before each case. The VerifEye Insulation Tester is equipped with an internal rechargeable battery and an array of next generation accessories.

For more information, visit steris-ims.com.

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product focus

Ecolab

OptiPro Multi-Enzymatic Automated Detergent Ultra Concentrate OptiPro Multi-Enzymatic Automated Detergent Ultra Concentrate is a highly concentrated multi-enzymatic detergent delivering outstanding cleaning performance under heavily soiled conditions. It is for use in automated washers. Features and benefits include advanced enzyme technology that provides superior cleaning results compared to other commercially available detergents.1 It is a non-foaming formula with a neutral pH. It is phosphate-free. OptiPro Multi-Enzymatic Automated Detergent Ultra Concentrate is suitable for the cleaning of surgical instruments and anesthetic utensils.

It is compatible with delicate materials including stainless steel, aluminum, zinc and nonferrous metals. As a highly concentrated liquid, it provides more uses in each gallon to minimize use cost and requires less storage space.

1. Ecolab Technical Monograph OptiPro Multi-Enzymatic Automated Detergent

For more information, visit ecolab.com.

Healthmark TOSI

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

The routine use of this test will help ensure that your instrument washer is performing at a consistent level, enhancing the routine visual inspection of instruments.

For more information, visit hmark.com.

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product focus

InstruSafe

da Vinci Tray Protection Products Protect your expensive instruments during sterilization, storage and transportation with a tray designed for easy and secure placements. InstruSafe Trays are designed in collaboration with Intuitive Surgical Inc., the maker of the da Vinci Surgical System. Instruments are organized with a medical grade silicone providing 360 degrees of protection. Discover this line of da Vinci protection products and start protecting instruments today.

For more information, visit instrusafe.com.

Ruhof

Elementum AW

Surgistain

Elementum AW, featuring four new molecules of enzymes created for the medical device cleaning market, is a multi-tiered enzymatic detergent that has been optimized* for the automatic, ultrasonic and manual cleaning of surgical instruments. Elementum AW is synergistically blended to produce the most powerful detergent for use on clinically used medical devices. This bestin-class solution has superior soil penetration and suspension, rapidly breaks down tough-to-clean medical soils, including the multi-layers of bioburden, and prevents redeposition.

Surgistain is a safe, efficient and quick revitalizing solution for stainless steel surgical instruments, trays, basins and case carts. The product removes rust, stains, spotting, hard water scale and mineral deposits frequently encountered from sterilization. It also helps to loosen stiff joints and locks. Regular use will enhance the life and efficiency of the instruments while lowering replacement costs.

*Elementum AW exclusively meets the qualifying characteristics of an optimal detergent per AORN, AAMI, and ASTM D8179 guidelines.

For more information, visit ruhof.com.

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continuing education

Cutting Out CLABSIs: Preventing Central Line-Associated Bloodstream Infections entral line-associated bloodstream infections (CLABSIs) affect an estimated 400,000 patients each year in the United States (AHRQ, 2018).

CLABSIs can cause serious infections and lengthen hospital stays, inflate medical costs, and increase the risk of morbidity and mortality. Nurses can play a significant role in reducing these troubling facts. Adhering to a group of evidence-based interventions known as the central line bundle has been proven to reduce the incidence of CLABSIs in healthcare settings. Components of the central line bundle focus on the proper insertion and maintenance of central lines to reduce infection rates. The nurse’s understanding of CLABSI, evidence-based bundle practices, and guidelines for the proper maintenance of central line catheters can improve patient outcomes significantly.

C

The goal of this educational program is to provide nurses in acute care settings with information about the severity and causes of central line-associated bloodstream infections and describe evidence-based interventions for the proper insertion and maintenance of central lines.

A Lurking Danger A silent killer lurks in every U.S. hospital: central line-associated bloodstream infection (CLABSI). It is estimated that each year approximately 400,000 CLABSIs occur in the United States (AHRQ, 2018). It is difficult to measure the mortality rate independently related to CLABSI because patient deaths are affected by multiple comorbidities. Three 32

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national data resources in the U.S. were used to estimate the annual number of deaths associated with healthcareassociated infections (HAIs) to be 98,987.

About one in three of these HAIs were due to CLABSIs. Therefore, the case fatality rate was about 12.3% (The Joint Commission, 2012). CLABSIs are usually serious infections (e.g., sepsis) that lengthen hospital stay, inflate medical cost, and increase the risk of mortality (The Joint Commission, 2012). The good news is that CLABSIs are preventable, and nurses have the power to reduce these troubling numbers (Zimlichman et al., 2013).This module focuses on preventing potentially deadly central venous catheterassociated bloodstream infections. Patients with a CLABSI stay in the hospital about 12 days longer than patients without a CLABSI (The Joint Commission, 2012).

The average CLABSI case cost ranges from $16,550 to $49,650, and CLABSI is associated with about 24,000 patient deaths each year (The Joint Commission, 2012). Simulations have shown, with 95% confidence, that CLABSIs are the costliest HAIs (Zimlichman et al., 2013).

Given this data, efforts to reduce the rate of CLABSIs are vital to improving healthcare quality and patient safety. The Institute for Healthcare Improvement (IHI) recommends five key measures based on best-practice guidelines to fight CLABSI (IHI, 2012): • Appropriate hand hygiene • Utilizing maximal barrier precautions on insertion of the central venous catheter (CVC) • Skin antisepsis using chlorhexidine • Optimal catheter site selection • Reviewing line necessity daily and removing lines promptly when they are no longer necessary

Relias LLC guarantees this educational program free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity.

See Page 39 to learn how to earn CE credit for this module.

Goal and Objectives After taking this course, you should be able to: • Describe the severity of CLABSIs. • Explain the causes and risk factors of CLABSIs. • Describe the five components of the central-line bundle.

Together, this group of evidence-based interventions is called the “central-line bundle” (IHI, 2012). The nurse’s understanding of CLABSI and evidence-based bundle practices can improve patient outcomes significantly.

Central Line Basics A central line, or central venous catheter (CVC), is a catheter inserted into patients who require frequent or continuous injections of medications, fluids, nutritional support, or therapies such as chemotherapy or dialysis (CDC, 2020). It is an intravascular device used for infusion, withdrawal of blood, or hemodynamic monitoring whose tip terminates at or close to the heart or in one of the great vessels. Location of central line placement depends on multiple factors including anatomy, body habitus, and infection risk. The most common insertion sites for adults are the subclavian vein (preferred), internal jugular vein, or femoral vein. The umbilical vein is more commonly used in neonates. The tip of the catheter most commonly terminates in the WWW.ORTODAY.COM

superior vena cava in adults. Based on specific patient factors and the purpose of the catheter, other great vessels in which the tip can terminate include the (CDC, 2020): • Aorta • Pulmonary artery • Inferior vena cava • Brachiocephalic veins • Internal jugular veins • Subclavian vein • External iliac veins • Common iliac veins • Femoral veins • Umbilical artery and umbilical vein (neonates)

Types of Central Lines A central line can be permanent or temporary. The CDC recognizes three different types of central lines for CLABSI reporting purposes (CDC, 2020): Permanent central lines can be accessed repeatedly for ongoing treatment such as dialysis or chemotherapy. These include tunneled catheters (such as those used for dialysis) as well as implanted catheters (such as ports).

Temporary central lines are not tunneled or implanted. These may pose greater inconvenience or discomfort to the patient as their lumens protrude from the insertion site for the duration of their placement.

Umbilical catheters are inserted through the umbilical artery or vein in neonates.

Central lines are crucial to medical management, particularly in intensive care, during major surgery, and during resuscitation because they provide secure vascular access and reliable hemodynamic measurement. However, central lines can cause multiple complications and the risks vs. benefits should be considered before placement.

Mechanical complications may occur simply from insertion. Some examples of mechanical complications include (O’Grady et al., 2017): • Pneumothorax • Subclavian artery puncture or vein laceration • Subclavian vein stenosis • Hemothorax • Air embolism • Thrombosis • Catheter misplacement WWW.ORTODAY.COM

Local infections at the insertion site can occur as well as systemic infections, such as CLABSI. An estimated 90% of all bloodstream infections are related to central venous access devices (AHRQ, 2018). CLABSI is a common culprit related to other specific infection-related complications including: • Septic thrombophlebitis • Endocarditis • Metastatic infection • Lung abscess • Brain abscess • Osteomyelitis • Endophthalmitis • Septic arthritis Despite the risks associated with CVC insertion, the secure access and monitoring they provide make them necessary in the management of critically ill or chronically ill patients. For this reason, CLABSIs remain a significant focus in the prevention of healthcare-acquired infections.

What is a CLABSI? To cause a catheter-related infection, microorganisms must access the bloodstream via the outside (extraluminal) or inside (intraluminal) surface of the catheter tube.

Microorganisms can enter the bloodstream in several ways (O’Grady et al., 2017): Skin contaminants enter through the insertion site and migrate along the catheter, colonizing at the tip (most common).

The catheter hub or catheter comes into direct contact with contaminated hands, fluids, or devices.

Microorganisms travel through the bloodstream and adhere to the catheter from a distant localized infection, such as pneumonia or a wound.

The infusing substances are contaminated (rare).

Again, the most common route of infection is migration of skin organisms at the insertion site, making aseptic technique during insertion and site care with dressing changes crucial to preventing contamination (O’Grady et al., 2017). After accessing the bloodstream, free-floating bacteria adhere to the catheter surface and form a microcolony. This leads to the formation of a biofilm, which allows sustained bacterial growth and spread throughout the bloodstream.

Clinicians should understand the differ-

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continuing education ence between clinical and surveillance definitions of CLABSI. The clinical definition is physician-driven and based on clinical signs and symptoms of BSI or sepsis, the blood culture laboratory results, and the presence of a central line. The surveillance definition of CLABSI is more specific and less subjective, and it relies on positive blood culture results and the presence of a central line.

The CLABSI definition in this module, developed by the Centers for Disease Control and Prevention (CDC) and the National Healthcare Safety Network (NHSN), has been adopted by most healthcare facilities to generate facilityspecific CLABSI rates. This definition lists essential criteria for surveillance of CLABSI and succinctly describes the methodology that should be used in CLABSI surveillance systems conducted by healthcare facilities.

According to the CDC/NHSN, CLABSI is a laboratory-confirmed BSI, such as bacteremia/fungemia, in a patient with a central line when no other infection source with the same microorganism is found. If a patient develops a BSI within two calendar days (or 48 hours) of insertion or removal of a central line, the BSI is said to be associated with the central line (CDC, 2020). If more than two calendar days pass between central line removal and the onset of infection, convincing evidence must exist before the infection can be classified as related to the central line (CDC, 2020).

Two criteria must be met before a BSI is classified as a CLABSI: • The patient must have both a central line and a laboratory-confirmed BSI. • The signs, symptoms, and blood culture laboratory results must not be related to an infection at another site.

If the same organism is found at a site other than the bloodstream, it is a secondary BSI rather than a primary BSI. For example, if both blood and wound culture results have shown Pseudomonas aeruginosa, the BSI is secondary, because the microorganism may have migrated from the infected wound into the bloodstream (CDC, 2020).

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continuing education Surveillance CLABSI Definition by CDC/NHSN Using the CDC/NHSN surveillance definitions for reporting purposes, a laboratoryconfirmed BSI requires that one of the following three criteria be met (CDC, 2020): Criterion 1 (both elements must be confirmed): • The patient (any age) has a recognized pathogen identified from one or more blood specimens by a culture- or nonculture-based microbiological testing method that is performed for purposes of clinical diagnosis or treatment.

• The pathogen is not related to an infection at another site.

Criterion 2 (all elements must be confirmed): • The patient (any age) has at least ONE of the following signs or symptoms: fever (greater than 100.4°F [38°C]), chills, or hypotension.

• The signs, symptoms, and positive laboratory results are not related to an infection at another site.

• A common skin contaminant is identified in two or more blood specimens drawn by a culture- or nonculture-based microbiological testing method. The cultures should be performed for purposes of clinical diagnosis or treatment on separate occasions, occurring within one calendar day of each other. The same skin contaminant must be found in both results.

• Examples of common skin contaminates: diphtheroids (Corynebacterium spp. not C. diphtheriae), Bacillus spp. (not B. anthracis), Propionibacterium spp., coagulasenegative staphylococci (including S. epidermidis), viridans group streptococci, Aerococcus spp., or Micrococcus spp.

Criterion 3 (all elements must be confirmed): • A patient younger than 1 year has 34

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at least one of the following signs or symptoms: fever (greater than 100.4°F [38°C], core), hypothermia (less than 96.8°F [36°C], core), apnea, or bradycardia.

• The signs, symptoms, and positive laboratory results are not related to an infection at another site.

• A common skin contaminant is identified in two or more blood specimens drawn by a culture- or nonculture-based microbiological testing method. The cultures should be performed for purposes of clinical diagnosis or treatment on separate occasions, occurring within one calendar day of each other. The same skin contaminant must be found in both results.

Examples of common skin contaminates: diphtheroids (Corynebacterium spp. not C. diphtheriae), Bacillus spp. (not B. anthracis), Propionibacterium spp., coagulase-negative staphylococci (including S. epidermidis), viridans group streptococci, Aerococcus spp., or Micrococcus spp.

A new criterion was added to the CDC/NHSN CLABSI module: mucosal barrier injury laboratory-confirmed BSI. This criterion is for patients with allogeneic hematopoietic stem cell transplant within a year or for patients with neutropenia, defined as at least two separate days with values of absolute neutrophil count or total white blood cell count less than 500 cells/mm on or within three calendar days before the date the positive blood culture was collected (Zimlichman et al., 2013).

The criterion also defines specifically the pathogens found in the blood culture (CDC, 2020).

The CLABSI criteria do not include catheter tip culture or treatment with antibiotics; therapeutic options are clinical decisions made by healthcare providers.

Blood cultures collected through central lines can have a higher chance of contamination than blood specimens drawn through peripheral venipuncture (CDC, 2020). Therefore, cultures ideally should be collected through venipuncture from two to four blood draws from separate sites. However, this may be difficult in patients with very poor peripheral venous access. Hospital administrators should work to ensure best practices in specimen collec-

tion. Blood cultures obtained from any site (through existing intravascular catheters, arterial lines, or venipuncture) must be considered in CLABSI surveillance.

Risk Factors for CLABSIs Despite associated complications, central lines remain necessary, especially when caring for patients in critical condition. Identifying risk factors that increase the incidence of CLABSIs is vital to preventing them. Some risk factors can be reduced through improved clinical practice, while others cannot.

Specific patient populations are more vulnerable to BSI, including (O’Grady et al., 2017; Marschall et al., 2014): • Older adults • Neonates or premature infants • Patients with severe medical conditions • Burn patients • Patients with cancer • Patients who are immunodeficient or immunocompromised • Patients with neutropenia • Organ transplant patients • Patients on dialysis While we cannot control the types of patients needing central venous access, we can reduce the risk for CLABSI by improving clinical practice. Ongoing research has identified several variables relating to central lines that can be affected to reduce the risk of infection.

Number of Lumens Multilumen central lines are indispensable in managing patients who require several IV medications, laboratory specimens, frequent blood product transfusions, and fluid resuscitations. However, they may be related to a higher rate of CLABSIs and thrombosis than singlelumen central lines (Ratz et al., 2016; Templeton et al., 2008). Multilumen catheters are manipulated more often, making colonization and bacterial growth at the tip more common. Hospital policies minimizing the number of lumens may reduce BSI and lower costs (Ratz et al., 2016). To reduce infection risk, the CDC recommends using the minimum number of lumens possible to meet the medical needs of the patient (O’Grady et al., 2017).

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Site Selection Use of the femoral vein for central line access in adults should be avoided under planned or controlled conditions (O’Grady et al., 2017; Marschall et al., 2014)). Femoral central lines have the highest rate of CLABSIs with increased incidence of deep vein thrombosis and catheter colonization. CLABSI due to gram-negative bacteria (e.g., E. coli and Enterobacter spp.) and yeasts is significantly higher in femoral CVC sites because of the proximity of the groin to the genital and perirectal area (Lorente et al., 2007).

The subclavian vein has the lowest rate of BSI, followed by the internal jugular vein. Therefore, the subclavian vein is preferred for inserting non-tunneled central catheters (O’Grady et al., 2017).

Umbilical catheters for neonates have special considerations and guidelines from the CDC. A link to the CDC website with these particular guidelines can be found in the Resources section at the end of this course.

Type of Infusion Central lines used to administer dextrosecontaining solutions, total parenteral nutrition (TPN), lipids, and blood-product transfusions are associated with increased incidence of BSI. Infusion of TPN and transfusion of blood products are considered a risk factor of CLABSI (O’Grady et al., 2017; Marschall et al., 2014). Microorganisms thrive in TPN and high-protein blood products. There is no recommendation regarding a specific port to use for either of these infusion types; however, tubing should be changed for these infusions at least every 24 hours (O-Grady et al., 2017).

Accessing the Central Line The manner in which lines are accessed can pose additional risk for infection. To protect patients, clinicians must use good antiseptic technique before accessing the central line. The following measures should be followed as outlined by the CDC guidelines (O’Grady et al., 2017): • Injection ports should be disinfected with an appropriate antiseptic before accessing the infusion system, with clinicians “scrubbing the hub” for at least 10-15 seconds.

• Examples: chlorhexidine, povidone WWW.ORTODAY.COM

•

• •

iodine, an iodophor or 70% alcohol Injection ports should be allowed time to dry before the infusion system is accessed.

Only sterile devices should be used to access the injection port.

Cap all stopcocks when the injection ports are not in use.

Catheter and Tubing Maintenance Failure to properly flush and maintain the lumens of the catheter or the tubing used for administration can increase infection risk. After infusions of IV solutions that may enhance microbial growth, catheters should be flushed with sterile, preservativefree 0.9% sodium chloride, according to organization policies and procedures and the manufacturer’s recommendations for the type of catheter. CDC guidelines recommend the following to address catheter lumens and tubing (O’Grady et al., 2017): • Tubing used to deliver lipid emulsions, blood, or blood products should be replaced within 24 hours of starting the infusion • The tubing used to administer propofol infusions should be replaced every 6 or 12 hours, when the propofol vial is changed, and per the manufacturer’s instruction.

• Replace administration tubing sets not used for blood, blood products, or lipids at intervals no longer than 96 hours.

Other risk factors that may increase the incidence of CLABSIs include: • Prolonged hospitalization before central line insertion • Prolonged duration of catheterization • Heavy microbial colonization at the insertion site • Heavy microbial colonization of the catheter hub • Inexperience of the clinician inserting the central line • High nurse-to-patient ratiO. Hospitals should keep nurse-to-patient ratios at least 2:1 in ICUs where nurses manage patients with central lines (Marschall et al., 2014).

Through increased awareness and improved practice, risk factors for CLABSIs can be effectively reduced to achieve optimal patient outcomes.

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continuing education The Complexity of Infection The development of a bloodstream infection (BSI) comprises complex interactions between the invading microorganism and immune system defenses. When infectious agents spread to the bloodstream, the fever-producing substances secreted by phagocytes will “turn up” the body’s hypothalamic temperature regulator.

Vasodilation substances are released from the mediators of the inflammatory process in response to overwhelming infection.

This triggers widespread vasodilation and reduced systemic vascular resistance, resulting in decreased blood pressure. The heart rate is altered (typically elevated) because of cardiac compensation. As a result, clinical presentation of BSI includes fever, chills, shaking, tachycardia, and hypotension. The timeline of infection can vary widely between patients, though an average time of eight days from insertion of a central line to onset of CLABSI has been reported (Lin et al., 2017).

The microbial profile of HAIs, including BSI, has changed over the past decades. In 1999, for the first time, more than half of all Staphylococcus aureus infections in ICUs were resistant to oxacillin.

When S. aureus resists oxacillin, it is also classified as methicillin-resistant S. aureus (MRSA), which has become endemic in many locations and often causes outbreaks. MRSA contributes significantly to increases in morbidity, mortality, and healthcare costs (O’Grady et al., 2011; Zimlichman et al., 2013; Karlowsky et al., 2004). From 2009 to 2010, 54.6% of blood cultures that tested positive for S. aureus were found to be resistant to oxacillin/methicillin (Sievert et al., 2015).

From 2009 to 2010, the species of bacteria most frequently isolated from blood cultures were, in rank order, coagulasenegative staphylococci, Staphylococcus aureus, Enterococcus faecalis, Candida spp. or not otherwise specified, Klebsiella pneumoniae/oxytoca and Enterococcus faecium (Sievert et al., 2015). Coagulasenegative staphylococci and S. aureus were by far the most common, comprising 20.5% and 12.3% of CLABSIs, respecMay 2022 | OR TODAY

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continuing education tively (Sievert et al., 2015). A more recent study on a population in which the central line bundle was utilized reported that the most common classes of microorganisms found in CLABSI cases were Gram-negative bacteria (39.2%), Gram-positive bacteria (33.2%), and Candida spp. (27.6%) (Lin et al., 2017).

Regardless of the causative organism, CLABSIs are life-threatening infections that are preventable with adherence to evidence-based practices such as the central line bundle.

Bundled Together The central line bundle correlates with the CDC’s BSI prevention guidelines (O’Grady et al., 2011; IHI, 2012). Use of the central line bundle dramatically reduces the incidence of CLABSI, and the reduction is sustainable (Richards et al., 2017; Scott et al., 2016). Research has shown that adhering to all elements of the central line bundle results in better outcomes than performing any of the five measures individually (Furuya et al., 2017; Lee et al., 2018).

The following is a description of the five key components of the central line bundle in more detail (IHI, 2012).

Hand hygiene: Good hand hygiene is the cornerstone of infection prevention.

Wearing sterile gloves does not eliminate the need for hand hygiene. Cleaning hands before inserting or manipulating a central line helps prevent contamination of central line sites and resultant BSIs. Hands should be washed with antimicrobial or non-antimicrobial soap and water with adequate rinsing, or cleaned with a waterless, alcoholbased hand sanitizer before donning sterile gloves.

The World Health Organization supports evidence from a study that identifies five key moments to perform hand hygiene (WHO, n.d.; Sax et al., 2007): • Before coming into contact with a patient • Before performing procedures that are clean or aseptic • After exposure or risk of exposure to body fluids (and after removal of gloves) 36

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•

After coming into contact with a patient • After coming into contact with the surroundings of a patient Maximal barrier precautions on insertion: The CDC identifies the following to provide maximal barrier precautions (O’Grady et al., 2017): • The clinician inserting the central line should wear the following: • Cap: All hair should be tucked under the cap • Mask: Mouth and nose should be covered tightly • Sterile gown • Sterile gloves • The patient should be covered from head to toe with a sterile drape.

• If a full-sized drape is unavailable, use two small drapes to cover the patient.

• A sterile dressing must be applied to the insertion site before the sterile barriers are removed.

• During insertion of all pulmonary artery catheters, a sterile sleeve should be used to protect the catheter.

Chlorhexidine skin antisepsis: The CDC recommends the following regarding skin antisepsis (O’Grady et al., 2017): • >0.5% chlorhexidine gluconate (CHG) in 70% isopropyl alcohol should be used to disinfect the insertion site and for site care during dressing changes.

• To prepare the site, press the applicator against the insertion site and apply the antiseptic solution using a back-and-forth friction scrub for at least 30 seconds. Allow the solution to air dry completely, according to the manufacturer’s recommendation, before CVC insertion or placement of a sterile dressing.

• Clinicians should never wipe the skin or blot to dry.

• According to the CDC, no recommendation can be made for using chlorhexidine-based skin antisepsis on patients younger than 2 months.

Optimal catheter site selection: In adults, the subclavian vein is preferred

for non-tunneled catheters (O’Grady et al., 2017). Subclavian venous access has a lower rate of CLABSI than internal jugular or femoral vein access. Caution should be used with subclavian placement because of the increased risk for mechanical complications (e.g., pneumothorax). Patient-specific medical risk factors (e.g., subclavian vein stenosis, coagulopathy, anatomic deformity) should be evaluated carefully when the insertion site is selected (O’Grady et al., 2017; IHI, 2012). For patients on hemodialysis or with advanced kidney disease, a fistula or graft is preferred to avoid subclavian vein stenosis (O’Grady et al., 2017).

• Ultrasound-Guided Insertion: Ultrasound scanners can be used to guide central line insertion to reduce the risk of mechanical complications. They have also been shown to reduce the number of sticks needed, which decreases the risk for CLABSI. For this reason, the CDC recommends the use of ultrasound scanners for insertion when they are available (O’Grady et al., 2017).

Daily review of line necessity with prompt removal of unnecessary lines: The risk of CLABSI is closely related to the length of time that a central line is in place.

When physicians and nurses conduct a daily review, unnecessary central lines are more likely to be removed promptly. A daily review of central line necessity can be incorporated into multidisciplinary rounds and daily goal reports (IHI, 2012).

Research has shown that there is still an opportunity to improve adherence to central line insertion practice and that adherence to central line insertion practices (CLIP) is positively correlated with CLABSI rate reduction (The Joint Commission, 2012; Bukhari et al., 2014). Every healthcare facility should develop strategies, including leadership involvement, policy development, educational courses, simulation training, and compliance monitoring, to improve adherence to CLIP. Using an electronic health record system can help nurses maximize the benefits of CLABSI-prevention strategies (The Joint Commission, 2012).

Beyond the Bundle The central-line bundle largely focuses on WWW.ORTODAY.COM

the insertion of the catheter rather than later management of the catheter site.

The following are recommendations and guidelines for issues that emerge after the catheter is inserted.

• Prophylaxis: Do not routinely administer intranasal or systemic antimicrobial prophylaxis before or during an intravascular catheter insertion in order to prevent catheter colonization or development of BSI (O’Grady et al., 2017).

The updated CDC guidelines state that if the CLABSI rate remains higher than the institutional goal despite other strategies (e.g., education and the central-line bundle), the use of antiseptic- or antibioticimpregnated short-term central lines is recommended (O’Grady et al., 2017).

Guidewires: Guidewires can be used to replace catheters that are not functioning properly or to exchange a pulmonary artery catheter for a central line. This has become a common practice but can also introduce an additional infection risk.

The CDC provides the following recommendations regarding the replacement of central lines and the use of guidewires (O’Grady et al., 2017): • Guidewires should not be used when replacing catheters in patients who are suspected of having an infection.

• Routinely replacing central lines to prevent BSI is not recommended.

• If no evidence of CLABSI is present, use a guidewire exchange to replace a malfunctioning non-tunneled catheter as appropriate.

• Clinicians should wear sterile gloves before handling the new catheter.

• Maximal sterile barrier precautions (including a cap; mask; sterile gown; sterile gloves; and a large, sterile full-body drape) must be applied during guidewire exchanges for intravascular catheters.

• A central line should be replaced as soon as possible (within 48 hours) if placed under conditions when aseptic technique could not be ensured, such as during medical emergencies.

Daily bathing with CHG: New research has shown that daily bathing with WWW.ORTODAY.COM

a 2% chlorhexidine skin cleansing product (for patients over 2 months of age) reduces the incidence of CLABSIs (Crnich & Maki, 2014; Marschall et al., 2014; Afonso et al., 2016). It is now an official recommendation from the CDC and The Joint Commission (O’Grady et al., 2017; The Joint Commission, 2012).

Catheter and insertion-site care (O’Grady et al., 2017; Marschall et al., 2014; The Joint Commission, 2013): • Accessing the catheter: When accessing the catheter, all sides and the top of the hub or injection port should be scrubbed vigorously for 10-15 seconds with 70% alcohol, alcoholic chlorhexidine, or povidone iodine.

• Caps that contain an antiseptic solution can be helpful in the prevention of CLABSIs but should be used in accordance with institutional policies (Marschall et al., 2014).

• Caps, needleless access ports, or claves should be changed no more frequently than every 72 hours.

• Protect the catheter: • Precautions should be taken to protect the catheter from the introduction of organisms during showering; avoid submerging the catheter in water.

• Patients with a tracheostomy are at increased risk for CLABSI if they have a central line at the internal jugular site. To protect the insertion site from being contaminated by respiratory secretions, nurses must keep the stoma clean and dry and change the tracheostomy holder when moist.

• A suture-less securement device is recommended to minimize movement of the catheter, which decreases the risk of organism migration from the skin.

Dressing guidelines and recommendations (O’Grady et al., 2017, Marschall et al., 2014): • For short-term, non-tunneled catheters: Dressings that are impregnated with chlorhexidine are recommended for patients aged 18 years and older to reduce CLABSIs.

IN THE OR

continuing education •

There is insufficient research regarding the use of these dressings in patients younger than 18 year of age, and severe adverse skin reactions may occur in premature neonates.

• Apply sterile gauze or a sterile, transparent, semipermeable dressing to cover the catheter insertion site.

• If the patient is diaphoretic or if the site is bleeding or oozing, apply gauze dressing until this is resolved.

• Immediately replace a dressing that is soiled, loosened, or damp; or if moisture, drainage, or blood is present under the dressing.

• Routine dressing changes: • Site care with a chlorhexidinebased solution should be performed with each dressing change.

• Transparent dressings for nontunneled central lines should be changed routinely, at least every seven days.

• Gauze dressings should be replaced at least every two days.

• For some pediatric patients, dressings may be replaced less often because the risk of dislodging the catheter may outweigh the benefits associated with dressing changes.

• Institutional central line care policies should address frequency of dressing changes.

• Do not use topical antibiotic creams or ointments on insertion sites other than for dialysis catheters or insertion sites. Such creams and ointments may promote antimicrobial resistance and fungal infections.

Assess the site: The CDC also reinforces the need for nurses to encourage patients to report any new pain or discomfort at the insertion site. If changes are reported, the nurse should remove the dressing completely and assess the site more closely. The site should also be directly assessed if the patient has a new onset of fever without another obvious May 2022 | OR TODAY

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IN THE OR

continuing education source or if there is suspicion of a localized or systemic infection related to the catheter (O’Grady et al., 2017).

Sufficient staffing: The number of staff as well as the type of staff caring for patients with central lines can affect CLABSI rates. Research has shown that a lower nurse-to-patient ratio (2:1 or 1:1) can improve staff adherence to bundle measures, which reduces infection rates (Aloush & Alsaraireh, 2018). Having more float pool or flex staff caring for patients with central lines can increase the risk for CLABSIs, possibly due to a lack of training or frequent exposure to this specific patient population (Alonso-Echanove, 2003). The CDC aligns with these findings and recommends ensuring adequate and appropriate staffing to reduce CLABSI rates (O’Grady et al., 2017).

A recent study showed approximately a 50% reduction in CLABSI rates when central line maintenance measures and the auditing process were standardized (Mathew et al., 2020). This study focused on scrubbing the hub, changing the needleless connector, CHG bathing, changing intravenous tubing, procedures for drawing blood cultures, and protecting the environment around the central line (Mathew et al., 2020). The results of this research reinforce the importance of not only proper insertion practices but also adhering to appropriate maintenance measures that can prevent infection.

All of these guidelines and recommendations are particularly important for nurses as they are the primary caregivers at the bedside after a central line is in place.

Adherence and Room for Improvement As mentioned earlier in this course, the central line bundle and associated recommendations are most effective in reducing infection rates with compliance of all components. In one of the largest studies completed, which involved over 1,000 ICUs in the United States, only 38% of the units reported full compliance with bundle measures (Furuya et al., 2016). This is concerning considering the large amount of evidence proving the effectiveness of the 38

OR TODAY | May 2022

central line bundle in reducing CLABSI rates and protecting vulnerable populations.

An analysis of existing research found that there is an abundance of research that proves the effectiveness of bundle measures and proper maintenance of central lines. It has been suggested that focus should shift from effectiveness of the bundle to improving adherence to bundle and maintenance measures (Ista et al., 2016).

Some barriers to adherence that have been identified include time constraints, lack of education, and lack of appropriate supplies (such as complete insertion kits or full body drapes) (Lee et al., 2018). Many providers continue to use the femoral site for central lines due to convenience. This can be due to anatomical considerations or attempts to decrease the risk for mechanical complications such as pneumothorax, however, infection prevention should take priority (Lee et al., 2018). Nurses should be empowered to advocate for appropriate site selection for planned and controlled insertions. Nurses can also encourage providers to strive for maximal barrier precautions, cover the entire patient, and ensure that supplies are available to do so.

It has also been found that taking the time to do daily assessments of line necessity is a challenge for the healthcare team.

This bundle measure was found to have the greatest need for improvement (Valencia et al., 2016). In a report of nurse opinions on the importance of bundle measures, daily evaluation of necessity was thought to be one of the least important and least performed bundle measures (Ng’ambi, 2018). Although it may take extra time, it is important for nurses to be involved in the daily assessment of central line necessity and to advocate for their removal as soon as possible. Bedside nurses are essential for identifying and relaying information about the progression of a patient’s condition.

This is especially important when certain medications such as vasopressors or TPN have been titrated or are no longer needed, and a physician may be unaware of recent changes. Nurses have the power to decrease CLABSI rates simply through facilitating removal when they are no longer needed.

Implementing an ongoing auditing process has also been shown to contribute to the reduction of CLABSIs (Mathew

et al., 2020). By holding staff accountable and continually “checking the boxes”, compliance can improve, therefore decreasing infection rates. Consistent monitoring of compliance through an auditing process has also been found to be an area in need of significant improvement (Valencia et al., 2016).

Nurses in Charge Nurses should be educated on the indications for central line insertion, proper insertion procedures, standardized care of central lines based on institutional policy, and the prevention of CLABSI. The Joint Commission requires nurses who care for central lines to attend hands-on training and competency validation to ensure proficiency of these skills (The Joint Commission, 2013). A hospital’s senior leadership is responsible for ensuring support for the nursing department and the infection prevention and control program that prevents CLABSIs. Healthcare providers are responsible for ensuring that optimal CLABSI prevention practice is always followed (Marschall et al., 2014).

To implement the central line bundle and ensure adherence, nurses should be empowered to supervise the insertion procedure. Nurses should have the authority to terminate procedures if they observe violations of hand hygiene, sterile technique, or evidence-based guidelines for the prevention of intravascular catheter-related infections.

Healthcare providers should be educated to increase their awareness of evidence-based infection prevention practice. Insertion kits, maximum barriers, and applicators with 2% chlorhexidine gluconate in 70% isopropyl alcohol should be kept in one location, such as on a single cart so that clinicians can obtain all central line insertion supplies easily. A central line insertion checklist should be developed to document adherence, and data should be collected for benchmarking (Marschall et al., 2014; Crnich & Maki, 2014). Nursing administrators should provide feedback to the appropriate healthcare providers on unit trends in the incidence and prevalence of CLABSIs and on the strategies to prevent them.

More and more patients are discharged with central lines in the form WWW.ORTODAY.COM

CE476

How to Earn Continuing Education Credit of PICCs, implanted ports, or dialysis catheters. Patients and families must be educated before discharge on caring for the catheter and preventing CLABSI. Providing written material can help the patient retain information. The Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America collaborated with the CDC on a compendium of practice recommendations to prevent HAIs, including CLABSIs. Clinicians can use this compendium as a reference (Marschall et al., 2014).

Joining Efforts The Centers for Medicare & Medicaid Services (2020) identified 14 categories of hospital-acquired conditions in the Inpatient Prospective Payment System Fiscal Year 2013 Final Rule. Vascular catheter-associated infection is one of 14 categories. In addition, hospitals accredited by The Joint Commission must establish practices to prevent CLABSI (The Joint Commission, 2019). Preventing CLABSI is a national patient safety goal (NPSG.07.04.01): Use proven guidelines to prevent infection of the blood from central lines. This Joint Commission requirement covers short- and long-term CVC and peripherally inserted central catheter lines (The Joint Commission, 2019).

Hospital administrators and the public are more aware than ever of the need to prevent HAIs. CLABSI is associated with increased medical expenses, morbidity, and mortality. It is largely preventable with evidence-based guidelines and an increasing awareness of the nurse’s role and ability to advocate for best care practices. A CLABSI rate of zero is the goal; patient safety is the priority.

Course Contributor The content for this course was created by May M. Riley, MSN, MPH, RN, ACNP, CCRN, CIC, FAPIC. MAY M. RILEY, MSN, MPH, RN, ACNP, CCRN, CIC, FAPIC, is is an infection control consultant at Stanford Health Care and a consultant editor for Critical Care Nursing Clinics of North America.

The content for this course was revised by Laura Bell, BSN, RN, CCRN. LAURA BELL, BSN, RN, CCRN, is a SME writer for Relias with 12 years of acute care experience in nursing. She began working in critical care at Wake Med Cary Hospital in 2011 and obtained her CCRN certification in 2016. She continues to work in the intensive care unit at Wake Med Cary Hospital as a supplemental staff nurse.

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 4/30/23 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

For references, visit ortoday.com/clabsi.

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May 2022 | OR TODAY

39

COVER STORY

NURSING

S H O R TA G E

PA N D E M I C M A G N I F I E S S T R E S S , W O R K F O R C E I S S U E S

By don sadler

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T

he U.S. health care system is facing an acute nursing shortage that was only made worse by the COVID-19 pandemic. This shortage is affecting every aspect of health care delivery, including perioperative services.

Before the pandemic, there were approximately 3.1 registered nurses in the U.S. Today this has dropped to 2.9 million nurses, according to the Bureau of Labor Statistics (BLS), and another half-a-million nurses are expected to retire this year alone. Open perioperative nursing positions have increased from 3% in 2012 to 11% in 2021.

Within the next two years, the shortage of nurses in the U.S. is expected to reach 1.1 million. The BLS projects a total of about 194,000 nurse openings each year through 2030, or a rate of job growth of 9 percent annually.

What’s more, a study conducted by the American Association of Colleges of Nursing (AACN) reports that one million nurses will retire by 2030. This is not surprising when you consider that the average age of perioperative nurses in the U.S. today is 46 years old and 76 percent of them are between the ages of 30 and 60.

Predictions Are Coming True “The predictions of the baby boomer generation retirements in nursing are and will continue to have a strong effect on the perioperative nursing shortage,” says Sharon McNamara, BSN, MS, RN, CNOR. “The large number of retiring nurses has resulted in a deluge of open positions that are taking an average of six months to fill.”

Vangie Dennis, MSN, RN, CNOR, CMLSO, assistant vice president, perioperative services at Anmed Health, says that the nursing shortage we’re experiencing today “was predicted 10 years ago. It is due to a number of different factors including retiring baby boomers, the stress of the work environment and a lack of sufficient nursing school professors.”

Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, the CEO and executive director of the Association of periOperative Registered Nurses (AORN), calls the shortage of nursing school faculty a “pipeline problem. There are more applicants for bachelor’s and master’s level nursing programs than there are faculty and other critical resources available to prepare them,” she says.

Groah cites an AACN report showing that more than 80,000 qualified applicants were turned away from nursing programs in 2019 due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors and budget constraints.

According to the 2021 AORN Salary and Compensation Survey, the top five reasons for the perioperative nursing shortage cited by nurses are: • Compensation and benefits • Staff changing employers or industry • Job burnout • Heavy workload/long hours • Job-related stress Meanwhile, in a 2021 survey conducted by the American Nurses Foundation, 41 percent of nurses cited insufficient staffing as the reason they wanted to leave their job, and 47 percent said that their work is negatively affecting their health and well-being.

David Taylor, MSN, RN, CNOR, the president of Resolute Advisory Group LLC, believes some causes of the nursing shortage are “multi-factorial. Each variable has numerous sub-variables and each compounds exponentially.”

“Nearly one-third of nurses leave the profession within the first two years of employment,” says Taylor. “If there were a few main causes of the nursing shortage, the most senior nursing professionals in the country would have devised a plan and fixed this problem years ago.”

Pandemic Increases Burnout Practically every expert notes the impact the pandemic has had on nurse burnout. “We don’t have specific data on this yet, but there is anecdotal evidence that caring for COVID patients in unrelenting numbers is leading to stress, burnout, resignations and retirements among some nurses,” says Groah. “The pandemic caused a perfect storm.”

Groah cites a 2021 American Nurses Association (ANA) Foundation survey that found that 35 percent of all nurses are not emotionally healthy. And in a 2021 American OrgaWWW.ORTODAY.COM

May 2022 | OR TODAY

41

COVER STORY THANK YOU TO OUR CONTRIBUTORS:

Vangie Dennis

MSN, RN, CNOR, CMLSO

David Taylor

MSN, RN, CNOR

nization for Nursing Leadership (AONL) survey of 1,800 nurse managers, 75 percent said that the emotional health and wellbeing of nurses was their top challenge.

In addition, 25 percent of nurse managers indicated that they were not emotionally healthy.

“Many nurses are working way more than a 40-hour week under extremely trying circumstances,” says Joanne D. OliverColeman, BSN, RN, CNOR-E, who is the CEO of Healthcare Resources. “And during the height of the pandemic, they feared that they may be bringing home the virus to their families.”

Meanwhile, Taylor cites a survey in which 30 percent of registered nurses nationwide reported burnout.

“Stress, anxiety, sleep deprivation, emotional exhaustion and depersonalization are some of the symptoms of nurse burnout,” he says. “These can decrease nurse retention rates and increase sick leave, which in turn increases nurse workloads and overtime compensation.”

According to Taylor, when ORs were reopened after being closed to elective procedures during the pandemic, perioperative nurses returned to “unrelenting schedules in order to work through the backlog of patients. There was literally no rest for the weary.”

Nurses have not had a chance to decompress and process the emotions and experiences they felt during the pandemic, adds Taylor. “It’s difficult to process the death of one’s patient when there are dozens of patients who need that bed, or to see truckloads of dead bodies and have to put on a happy face so you can care for the next patient,” he says.

ECRI: Staffing Shortages Threatens Patient Safety

Linda Groah

MSN, RN, CNOR, NEA-BC, FAAN

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Staffing shortages top a list of patient safety concerns released by ECRI, the nation’s largest nonprofit patient safety organization.

While the annual list is typically dominated by clinical issues caused by device malfunctions or medical errors, ECRI researchers say the most significant concerns at present are caused by crises that have simmered, but COVID-19 exponentially worsened.

“Shortages in the health care workforce and mental health challenges were broadly

known and well-documented for years,” said Marcus Schabacker, MD, Ph.D., president and CEO of ECRI. “Both physicians and nurses were at risk of burnout, emotional exhaustion and depression prior to 2020, but the pandemic made both issues significantly worse.”

While both trends were known, their effect on patient care was not well documented. Now, ECRI researchers say inadequate staffing is actively jeopardizing patient safety. Due to staffing shortages, many patients are waiting longer for care, even in life-threatening emergencies, or simply being turned away.

With reports of more health care workers planning on leaving the industry, ECRI experts say patients could face even higher risks without proactive solutions. Without intervention, the chaos and understaffing in hospitals and other health care settings seen over the last two years could become the new normal for the foreseeable future.

“Health care and government leaders now must aggressively manage these challenges amidst a lingering pandemic and a weakened health system by prioritizing recruitment, retention and clinician resilience,” Schabacker said. “As leaders, their most important job is ensuring that patient health and safety are top priorities.”

“ECRI’s report is a roadmap to help prioritize patient safety initiatives and allocate necessary resources that accelerates organizations in their total system approach to safety,” said Brigitta Mueller, MD, executive director of patient safety, risk and quality at ECRI. “We are here to help health care and government leaders as they finally address these longstanding issues in a comprehensive, forward-thinking way.”

To identify the most pressing patient safety threats, ECRI analyzed a wide scope of data, including scientific literature, patient safety events or concerns reported to or investigated by ECRI, client research requests and queries, and other internal and external data sources.

ECRI’s Top 10 Patient Safety Concerns for 2022 report provides detailed steps that organizations can take to prevent adverse incidents and is available for download.

Unique Perioperative Challenges The nursing shortage is especially challenging in the perioperative environment WWW.ORTODAY.COM

because of the highly specialized nature of perioperative nursing and the extra training required to get nurses up to speed.

“There are more than 15 OR surgical specialties and each of them has technology specific to the specialty,” says Groah.

“It can take OR nurses nine to 12 months to be oriented in one or two specialties and up to two years to be oriented in all surgical specialties.”

“Due to the omission of perioperative patient care in standard nursing curriculum, extensive specialized education and skills acquisition are required before new graduates can function effectively in surgical services,” says McNamara. “This requires an extended orientation period to prepare perioperative nurses.”

It also falsely gives the impression that perioperative nursing positions have been filled with nurses who can function independently. “In reality, the nurse shortages continue during the orientation period,” says McNamara.

One solution some organizations employ to help combat the nursing shortage is to use traveling nurses. “We have feedback from our members about the need to use travelers to meet the daily staffing needs in the OR, both in hospitals and ambulatory surgery centers (ASCs),” says Groah.

“More hospitals are now hiring traveling nurses to backfill,” adds McNamara. “These travelers who may not work weekends or take call are usually paid more than loyal, employed nurses.”

This can lead to low morale on the part of staff nurses, says Oliver-Coleman.

“Agency nurses are sometimes being brought in to cover at three to four times the pay of staff,” she says.

“If nurses are going to work this hard, many will choose traveling which gives them controlled hours of work and higher pay,” adds Dennis.

Solutions to Solve the Shortage While there’s no silver bullet, experts offer a wide range of potential solutions to help solve the nursing shortage. Taylor would like for there to be a national strategy devoted to solving the problem.

“I’d especially like to see greater efforts to recruit and transition nursing students into professional roles in a timely manner and the creation of pipelines for clinical WWW.ORTODAY.COM

partners to help fill shortages,” says Taylor.

Hiring bonuses, tuition reimbursement, loan repayment, tiered referral bonuses and internship programs would also help, Taylor adds.

“Hospitals can also offer concierge services like dry cleaning and automotive services to nurses that help them get their errands done during the day so they can relax while they’re off,” he says. “On-site day care can also benefit nurses greatly.”

Dennis would like to see more investment in schools of nursing by supporting relief of student debt. “So many nurses have large student loans,” she says. “The pay structure for perioperative nurses also needs to be re-evaluated.”

Oliver-Coleman stresses the importance of using experienced nurse mentors to help train new perioperative nurses.

“Also use retirees as adjunct faculty and offer flexible hours whenever possible,” she says. “We all need to be more flexible with alternative staffing to include staggered shifts, agency nurses (with appropriate orientation) and parttime retirees.”

According to Groah, AORN has recently partnered with Chamberlain University to incorporate Introduction to Perioperative Nursing into its curriculum on four campuses, with plans to expand throughout their system.

“This program exposes nursing students to a clinical setting where they are a valuable member of a high-performance team,” says Groah. “Students can experience the importance of lifelong learning as technology advances, as well as vital connections with patients and their families.”

When these students graduate, they will better understand what the specialty of perioperative nursing entails and be ready to enter Periop 101: A Core Curriculum OR. This is AORN’s six-month program to train novice nurses in perioperative nursing.

“Periop 101 is the premier perioperative nurse education program for RNs entering the perioperative specialty,” says Groah. “Hospitals and ASCs that use Periop 101 report quality improvement, reduced training time for staff and educators, and stronger staff recruitment and retention.”

New Think Tank and Task Force To help solve the nursing shortage challenge, the ANA – in collaboration with the AONL, the Association of Critical Care Nurses (ACCN), the Healthcare Financial Management Association (HFMA) and the Institute for Healthcare Improvement (IHI) – is launching a nurse staffing think tank.

The goal of the think tank is to link nurses and workforce experts who are interested in driving solutions to the nursing shortage. It will do this by reviewing data to uncover root causes of the shortage, identifying implications that may not have been considered, and developing strategies that health care organizations can implement within one year with measurable outcomes for impact.

These same five organizations have also launched a National Nurse Staffing Task Force with four key goals: • Provide a forum for a powerful dialog on a national scale to address critical issues.

• Facilitate progress toward innovative solutions that are consistent with appropriate staffing in acute and critical care settings.

• Build the nursing workforce through long-term sustainable recruitment and retention solutions.

• Support and sustain a healthy work environment using principles and guidelines for appropriate staffing that correlate with optimal nurse satisfaction, care outcomes and patient safety.

Last September, the ANA called on the Department of Health and Human Services (HHS) to take concrete action to address the nursing shortage. Specifically, the ANA called on HHS to take actions to achieve pay equity and full scope of practice for advanced practice RNs, as well as to enhance nurses’ mental health support.

The ANA, AONL and HFMA have published an outcomes-based staffing report titled “The Business of Caring: Promoting Optimal Allocation of Nursing Resources.” The report sets forth an action plan for improving the allocation of nursing resources.

A free download of the report can be found at aonl.org/resources/the-business-of-caring.

May 2022 | OR TODAY

43

SPOTLIGHT ON:

Marisa Streelman

By Matt Skoufalos

arisa Streelman had considered a career in medicine long before a health careers program at her Flint, Michigan high school offered her the opportunity to preview a handful of hospital jobs prior to college.

Although Streelman initially had planned to become a physician, after having been exposed to the work of nursing teams at the hospital, she noticed how much more patient interaction nurses experienced than physicians did — and that was the work with which she felt most connected. It was then that Streelman realized she’d be better off studying nursing.

M

“My calling was really around helping the patients, so I flipped my mind around,” Streelman said.

After completing her BSN at Eastern Michigan, Streelman began her nursing career at an oncology unit at Northwestern Memorial Hospital in downtown Chicago, Illinois. From delivering palliative care and symptom management, she learned a lot about what patients experience when the internal functions of their bodies are disrupted by cancer. She continued to work as a charge nurse for several years until she began feeling an itch to do something else.

“I’m a person who looks for challenges and opportunities,” Streelman said. “I had a great mentor, and she said, ‘Why don’t you look at management?’ I ended up loving it, and I stayed in nursing leadership for about 13 years.”

Streelman spent three of those 13 years at Northwestern Memorial before moving on to a cardiac step-down unit at University of Colorado Hospital for two years. Afterward, she headed back to Chicago to manage a general medicine unit at Rush University Medical Center for seven years.

During that time, Streelman followed up the master’s degree in nursing administration she’d earned from the University

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OR TODAY | May 2022

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When not working Marisa Streelman enjoys spending time with family.

of Illinois Chicago with a doctorate of nursing practice from Rush University, which covered the costs of her advanced schooling while she worked at the university hospital. Her advanced educational goals streamlined nicely with Streelman’s wholehearted embrace of nursing leadership; she especially enjoyed mentoring new nurses as they sought out the career paths that best fit their temperament and lifestyle choices.

“I think of nursing like a tree with branches,” Streelman said. “You have all these aspects of care – virtual nursing, triage, ICU, critical care, CRNA – and there’s all these different avenues to look at. In a formal leadership role, helping new nurses understand where their paths would lead, I loved bringing new nurses in, orienting them, and watching their careers grow and progress.”

After her time in Chicago, Streelman returned home to Michigan, where she now works as a staff specialist at the University of Michigan Hospital in Ann Arbor. Streelman described her role there as an informal leadership role in the surgical subsegment that merges project management duties with those of nursing inpatient units, where she works to limit the impact of hospital-acquired conditions like pressure injuries and central line infections as well as falls.

During the last few years, Streelman helped specialized nursing units transform into facilities capable of supporting novel coronavirus (COVID-19) patients, and then flipping those units back to their normal applications throughout four waves of COVID-19 infections. As Streelman has progressed through these duties – which included supporting a 50bed regional infection containment unit WWW.ORTODAY.COM

Marisa Streelman is very active in AMSN.

for overflow patients during the peak infection waves of the pandemic – she relied on her knowledge of nursing leadership roles to help facilitate the effective management of those units.

“The COVID crisis has put a lot of emphasis on the nursing world,” Streelman said. “Some of the issues were there before, but a lot of them have come to light, and been visualized much more broadly during the pandemic.”

“...As the leader, I am not less affected or stronger than anyone else. We are in this together, and we need each other.

No one is alone.”

“I think about the nursing units; what they’re going through with trying to get enough staff to work,” she said.

“We’re all struggling. How can we help each other? Leaders can’t work alone.

You have to work with others. It’s too hard to try to do it by yourself; it’s not as easy to ask for help.”

Streelman’s perspective on nursing leadership is informed by more than a decade of participation in the Academy of Medical-Surgical Nurses (AMSN), beginning with her establishment of an AMSN chapter in Chicago, her participation in the scholarship and awards committee for AMSN, and her eventual service on the national board of the organization, first as treasurer and director, and eventually as its president-elect in 2022.

“It’s been wonderful,” Streelman

said. “The relationships and support that AMSN and staff have given me have been fantastic. I’ve formed lifelong friendships, as well as this feeling of supporting the medical/surgical nurse and advocating for them. You get that satisfaction of looking and thinking about nursing differently than you do from your daily work. It’s inspiring to see everyone coming together and wanting to do great work.”

During the pandemic, Streelman carried those perspectives with her in supporting nursing leaders at the University of Michigan. Speaking as a nursing leader, she gave voice to her own struggles during the pandemic, which empowered other nurses in different specialties to do the same. Sharing the emotional burden of that vulnerability encouraged her peers to do so as well, and Streelman said her team rallied around her in the effort.

“When you come into these situations that are all-encompassing, don’t be afraid to reach out,” Streelman said. “Leaders need wellness as much as their staff. I find in my leadership life that when I am more vulnerable with my staff, I feel more supportive. It’s letting people know that it’s OK to not be OK, and you’ve got to work with others.”

“Oftentimes, units work so much in silos that you need to come together and understand you’re not the only ones going through this,” she said. “Make sure you talk to your coworkers, your peers.

Your team will rally around you.”

“It’s OK for people to know that this is impacting all of us,” Streelman said; “to know that, as the leader, I am not less affected or stronger than anyone else. We are in this together, and we need each other. No one is alone.”

May 2022 | OR TODAY

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OUT OF THE OR health

Photo courtesy of Getty Images

How to Find the Right Doctor

By Family Features hether you’re rarely sick or have

W conditions that require frequent visits to

the doctor, having a trusted and skilled health care provider is an important step in protecting your health.

Any number of reasons can result in needing to find a new doctor, such as moving to a new community, changes to your insurance, your old doctor retiring or needing a specialist.

These suggestions from the Centers for Medicare & Medicaid Services (CMS) can help you be more efficient and thorough as you look for a doctor who is right for you.

Ask for Recommendations Talk to people you know about whether they have a provider they like. If you’re looking for a new provider because of a move or retirement, ask your current doctor for a recommendation. If you need to make a change with your primary care doctor but see specialists or other medical professionals you like and trust, you can also request referrals from them.

Check with Your Insurance Company If you have health insurance, you may need to choose from a list of doctors in your plan’s network. Some insurance plans may let you choose a doctor outside your network if you pay more of the cost.

To find a doctor who takes your insurance, call your

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OR TODAY | May 2022

insurance company and ask for a list of doctors near you who are in-network or use the insurance company’s website to search for a doctor. It’s also a good idea to call the doctor’s office and ask for confirmation they take your plan. You should have your insurance, Medicare or Medicaid card handy in case the office needs your plan details.

Narrow Your Options Some of the providers you consider may not be viable options for simple reasons, like their practice isn’t currently taking new patients or they don’t have office hours matching your schedule. You can also consider questions such as hospital affiliations and whether other providers can help if you need emergency care and your doctor isn’t available.

Take a Deeper Look Online research can tell you a great deal about potential doctors, from biographical information and credentials to ratings by former patients.

When searching for a new provider, another important area to consider is financial relationships.

One resource patients can consider is Open Payments, a national disclosure program within CMS that provides visibility into financial relationships between drug and medical device companies and physicians, and teaching hospitals. The government requires pharmaceutical companies, device manufacturers and group purchasing organizations to report funds

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OUT OF THE OR health

they give health care providers in the form of meals, entertainment, travel, gifts, consulting fees, research payments and more, promoting transparency and helping uncover potential conflicts of interest.

It’s important to know most health care providers receive payments. Just because financial ties are reported does not mean anyone has done anything wrong. However, patients can use the information to talk with their provider about why they recommend certain medications or treatments, including asking about generic options, which are equally as effective as name brands but typically less expensive. It’s also an opportunity to start a discussion with a provider about areas of professional interest and expertise based on research or consulting.

Listen to Your Gut If you’re undecided, request an introductory appointment with a provider you’re considering. Look for a clinic where you are treated with respect and the medical team listens to your opinions and concerns. You should feel comfortable asking questions, and the doctor needs to be able to explain things in ways you understand.

Find more resources for your health care needs at cms.gov.

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47

OUT OF THE OR fitness

The Best Mobility Exercise You’re Not Doing for Your Hips

By Miguel J. Ortiz here are plenty of stretches and mobility drills to strengthen the hips, but the most important is the Hip Controlled Articular Rotation (Hip CAR). It is the best way to ensure you are maintaining and strengthening the hip joint to its fullest capacity. Flexibility plus strength equals mobility.

T

The reason Hip CAR works so well is because when done properly the hip is taken through simultaneous flexibility and strength when in different positions in order to move the joint through its full range of motion. This movement takes time and consistent practice to master.

There are different variations to try. Each will challenge the hip in a unique way.

The first Hip CAR to try is side lying because it’s easier on the rest of the body. The set-up is fairly simple and isolates the hip in a way to prevent less compensation.

The controlled articular rotation means that each rep needs to be controlled throughout its entire range of motion, so from a neuromuscular standpoint it’s very easy to compensate and create unnecessary movement to

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OR TODAY | May 2022

try and get the job done. We want to complete this movement as smoothly as possible trying as best as we can to not “borrow” muscles from other areas to help the hip complete its range of motion.

The next is a Seated Hip CAR. This one challenges the core a little bit more. You may need to use blocks if you find yourself leaning over a lot to complete the rep. As the movement progresses, so does the ability to control the Hip CAR in its entirety.

The third variation is the Quadruped Hip CAR where you start on your knees and hands. This one can be difficult because to bring your leg all the way around requires a fairly deep amount of flexibility in your inner thigh.

This is just another example of how each Hip CAR becomes more challenging on the hip and the surrounding muscle groups.

The fourth is a Half Kneeling Hip CAR. It can be done against a wall in your home. The only equipment you really need is a mat.

For beginners, the yoga blocks will go a very long way. By being in a kneeling position, you really start to see the vulnerability in your core balance and stabilization as leaning and shifting becomes easier to do.

You really want to focus on keeping your core braced and your arms pressed against the wall in a strong position.

Our fifth and last is the Standing Hip CAR. This is probably the most advanced. Its easier to make compensations so ensuring you have the first 4 movements down is important.

The bracing in your core, your breathing, keeping the rest of your body tight and engaged all matter when it comes to performing the Standing Hip CAR properly.

So, start implementing Hip CARs into your routine. You’ll be on your way to loosening and strengthening your hips for better overall movement and quality mobility. Have fun with your exercise and remember to stay active.

– 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. Readers can find videos of the exercises under the “videos” tab at tinyurl.com/ORTfitness.

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49

OUT OF THE OR EQ Factor

Are You Prioritizing Your Schedule or Scheduling Priorities?

By Daniel Bobinski ave you ever heard the phrase, “All things are created twice?” That phase sits at the heart of habit two from Stephen Covey’s bestselling book, “7 Habits of Highly Effective People.” Habit two is called, “Begin with the end in mind,” and it correlates to what Covey calls the first creation. It’s called first creation because begin with the end in mind is something that occurs in our heads. The second creation occurs when we create the functional finished product.

H

In the recent past, I’ve used this space to talk about goal setting, because setting goals involves mentally clarifying an end result (first creation).

A great example of this is designing a house. Before building can begin, one must make decisions about the purpose, function and layout of the house. If a family plans on entertaining a lot, a large, open floor plan will likely be necessary.

If people will work from home, then workspaces must be included. If lots of children are involved, multiple bedrooms and bathrooms are a necessity.

Other questions to consider: What kind of heating system will be used?

Where will the windows be? Will walk-in closets or a butler’s pantry be needed?

Once these decisions are made, an architect creates a blueprint of the

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OR TODAY | May 2022

design. All this activity correlates to “first creation.” It’s a mental process of beginning with the end in mind, because if a well-thought-out plan doesn’t exist, making changes during the actual construction phase gets very expensive!

After the first creation (habit two) is Covey’s third habit, which is “Put first things first.” Another way to say this is prioritize, and then act according to your priorities. Habit three represents the second creation. It’s the actual doing of what was identified and planned in the first (mental) creation.

Prioritizing When we plan our weeks and months, Covey offers the following advice: “Don’t prioritize your schedule; schedule your priorities.” What he means is that each of us should decide what is important for our lives and make sure those action items get onto our calendar. To do that, we must first learn to differentiate between important and urgent.

Urgent activities are things that require immediate attention. Think of it as, “things will go south really quickly if this urgent matter isn’t addressed.”

Important activities are those that contribute to your mission, values and high-priority goals.

Using what’s known as the Eisenhower Matrix, Covey points out that everything we do falls into one of four categories:

• Quadrant 1: Urgent – Important • Quadrant 2: Not Urgent – Important • Quadrant 3: Urgent – Not Important • Quadrant 4: Not Urgent – Not Important Quadrant 1 activities (urgent – important) will always be around, but these tend to be stressful and eat up much energy.

However, if we prioritize Quadrant 2 activities (not urgent – important) and put them on our calendars, not only will we get more of our own goals accomplished, but over time we’ll have less Quadrant 1 things to deal with.

This is an important aspect about being effective, so we’ll explore this more in next month’s column!

Daniel Bobinski, M.Ed. is a best-selling author and a popular speaker at conferences and retreats. For more than 30 years he’s been working with teams and individuals (1:1 coaching) to help them achieve excellence. He was also teaching Emotional Intelligence since before it was a thing. Reach Daniel by email at DanielBobinski@protonmail. com or his office at 208-375-7606.

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51

OUT OF THE OR nutrition

Eggs Are In Season

By Kirsten Serrano hen you envision seasonal eating in W spring, produce like asparagus and

strawberries may leap to mind. In fact, most proteins have a season when they are at their best as well and that is certainly the case for eggs. They are nutrition powerhouses that peak in quality in spring and summer if you know what to look for.

Why do eggs have a season? Because a hen needs 14 hours of light to lay eggs. Laying peaks at around 16 hours of light. It’s biology. As days lengthen in spring, biology kicks in and more eggs are laid. Of course, we can provide artificial light, but there is another reason spring eggs are the best. That reason is all about the link between input and output.

Eggs are a standout example of how much input matters when it comes to nutrient-density. We’ve had chickens on our farm for a dozen or so years. As soon as we started collecting our own farm’s eggs, I was blown away by the color of the yolks and the intense flavor. Now, if I eat a commercial egg, I can tell by its taste all the nutrients the hen and I are missing. Flavor and nutrition go hand in hand!

Chickens are omnivores that are treated like herbivores by industrial agriculture. The next time you are in the grocery store, notice the packages of

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OR TODAY | May 2022

chicken and cartons of eggs that proclaim the chickens have been fed a vegetarian diet. It’s silly. I guess Americans don’t like the idea of chickens eating meat, but chickens sure do. This is a perfect example of how poor food and farm literacy is undermining our health and the health of millions of animals. Hens do eat grains, but they also love to eat grasses and other foliage, plus bugs, worms, caterpillars, rodents, frogs, and even snakes! If they can catch it, they will eat it.

A truly pastured hen lays an entirely different egg than the poor vegetarian-fed hen that never sees the light of day. (By the way, cage free designations on eggs mean nothing. The hen might be better off in a cage.) She is free to roam, select her own food (including protein), and her egg compared to a conventional one. 1

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OUT OF THE OR

nutrition

It would be great if these flavorful and supernutritious eggs were the norm, but they are not.

Here’s my advice for finding great quality eggs at the grocery store and beyond.

• At the grocery store, look for organic, pastured (or free-range), USDA A or AA, stamped with the Certified Humane or Animal Welfare Approved seal. These eggs are worth the extra money.

• Get them from a local farm. Talking to the producer is always the better option and will most likely get you a better product than you will ever see at the store. Getting high-quality local foods is easier than ever. I live smack dab in the middle of nowhere and I can get these eggs delivered to my door once a week.

• This option may not work for you, but it is worth considering. Get a few backyard hens.

Even if you are in a city, many urban areas are friendly to backyard chickens and they are quite easy to take care of. Two or three chickens can easily provide enough eggs for a

family with enough to occasionally share. There are plenty of plug and play structures available to keep them safe and happy.

However you do it, I urge you to choose the better egg. It will nourish you and it’s the right choice for the chicken and the planet.

1 Alterman, Tabitha. “More Great News About Free-Range Eggs | MOTHER EARTH NEWS.” Mother Earth News, 2009, www.motherearthnews.com/natural-health/free-rangeeggs-zmaz09fmzraw. Accessed 1 Jan. 2020.

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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53

OUT OF THE OR recipe

Flatbread with Caramelized Onions, Bacon and Arugula

Recipe

INGREDIENTS:

the

•

1

tablespoon butter

•

1/2

tablespoon olive oil

•

1

large sweet onion, sliced

•

1/2

teaspoon balsamic vinegar

•

1 naan flatbread (rectangular shape)

•

1

cup cheddar cheese, shredded

•

1

cup fontina cheese, shredded

•

4

slices bacon

•

arugula

•

olive oil (optional)

•

lemon juice (optional)

By Family Features

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OR TODAY | May 2022

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OUT OF THE OR recipe

Step Into Spring with a Sweet, Fresh Meal pportunities for dining outdoors and soaking up the sunshine abound. Patio meals often mean fresh flavors, making this a perfect time for heading outside with your favorite seasonal dishes.

ful recipes like this Flatbread with Caramelized Onions, Bacon and Arugula. Start by heating butter and olive oil then allow the onions to rest in the mixture; once they’re sweating, turn the heat down and cover the pan. Stirring every 10 minutes, cook for about 40 minutes until the onions reach a deep golden brown. In the final 10 minutes, stir in balsamic vinegar for savory flavor.

Layer the sweet, caramelized concoction along with cheese and bacon on a flatbread.

Bake (or grill, if the weather allows) for 15 minutes before topping with fresh arugula for a lighter dish that reminds you springtime has arrived.

O

The freshness of Texas 1015 Sweet Onions is an ideal starting point for recipes that heighten the enjoyment of al fresco dining. As the first spring sweet onion of the season, they’re harvested and packed fresh, meaning they’re never stored. Plus, with no burning sensation when you cut them, you can skip the tears for more enjoyable meal prep.

It’s a versatile veggie that can be grilled, roasted, eaten fresh or caramelized for delight-

Find more recipes to celebrate spring at tx1015.com.

Flatbread with Caramelized Onions, Bacon and Arugula

2.

To make flatbread: Preheat oven to 425 F.

Recipe courtesy of South Texas Onions

3.

On flatbread, layer cheese, bacon and caramelized onions. Bake 13-15 minutes, or until cheese is bubbly and edges are golden brown.

4.

Toss arugula with olive oil and lemon juice, if desired, before placing on flatbread.

Servings: 2-3

1.

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To make caramelized onions: In pan over medium-high heat, heat butter and olive oil. Add onions and let sit about 5 minutes. Once onions start sweating, turn heat to low and cover pan. Cook onions to deep golden brown, stirring every 10-15 minutes. With 10 minutes left, stir in balsamic vinegar.

May 2022 | OR TODAY

55

OUT OF THE OR pinboard

CONTEST Win a $25 Gift Card!

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“OR Today magazine is learning never ends in the operating room. I teach the next generation of certified surgical technologist to embrace the idea of constant learning.

There is something new everyday in this profession.”

– Cindy Mask,

Assistant Professor of Surgical Technology

H QUOTE OF THE MONT . It does.” e c n re e iff d a s e k a do m “Act as if what you mes – William Ja

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OR TODAY | May 2022

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SCRAPBOOK AORN

SCRAPBOOK fter a three-year COVID-19 break, the AORN Expo burst back onto the scene this year. The largest perioperative nursing conference in the world was the place to be as more than 1,000 health care professionals from around the world arrived in New Orleans. It was a large and especially enthusiastic crowd after the pandemic-imposed hiatus.

A

1

2

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. An exhibit hall filled with the top companies that service the perioperative market and fun-filled networking events added to the conference experience.

3

8 4

6

5

7

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1. OR Today’s booth inside the exhibit hall.

2. Who doesn’t love a puppy adoption inside the exhibit hall?

3. Healthmark Industries provides real, in-person examples to demonstrate its equipment.

4. Kennedy Krieg meets highlighted professionals from previous issues of OR Today magazine.

5. The STERIS team at AORN 2022.

6. Xodus Medical brought a life size Pink Pad® to the conference!

7. MD Publishing Vice President, Kristin Leavoy, takes a selfie with Xodus Medical’s life size Pink Pad®!

8. Ben C. from MedWrench stopped

by Cafe Du Monde for some New Orleans beignets!

May 2022 | OR TODAY

57

INDEX

advertisers

ALPHABETICAL AIV Inc.……………………………………………………………… 47

Encompass Group…………………………………………… 49

MD Technologies Inc.……………………………………… 20

ASCA………………………………………………………………… 49

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

Ruhof Corporation…………………………………………… 2-3

BD……………………………………………………………………… 25

I.C. Medical, INC.………………………………………………… 5

SIPS Consults………………………………………………………15

C Change Surgical………………………………………………19

Innovative Medical Products………………………… 59

TBJ Incorporated………………………………………………… 4

CIVCO Medical Solutions………………………………… 11

Jac-Cell Medical……………………………………………… 53

Welmed, Inc.……………………………………………………… 23

Cygnus Medical………………………………………………… BC

Jet Medical Electronics Inc………………………………51

Ecolab Healthcare……………………………………………… 8

Key Surgical……………………………………………………… 27

CATEGORICAL ASSOCIATION

Ecolab Healthcare……………………………………………… 8 Welmed, Inc.……………………………………………………… 23

TBJ Incorporated………………………………………………… 4

ASCA………………………………………………………………… 49

CARDIAC PRODUCTS

INFECTION CONTROL

Healthmark Industries Company, Inc.……………17 Key Surgical……………………………………………………… 27

C Change Surgical………………………………………………19 CIVCO Medical Solutions………………………………… 11 Jet Medical Electronics Inc………………………………51 Welmed, Inc.……………………………………………………… 23

CARTS/CABINETS CIVCO Medical Solutions………………………………… 11 Cygnus Medical………………………………………………… BC Healthmark Industries Company, Inc.……………17 TBJ Incorporated………………………………………………… 4

CS/SPD CIVCO Medical Solutions………………………………… 11 Ecolab Healthcare……………………………………………… 8 MD Technologies Inc.……………………………………… 20 Ruhof Corporation…………………………………………… 2-3 Welmed, Inc.……………………………………………………… 23

DISINFECTION CIVCO Medical Solutions………………………………… 11 Cygnus Medical………………………………………………… BC Ecolab Healthcare……………………………………………… 8 Ruhof Corporation…………………………………………… 2-3

DISPOSABLES CIVCO Medical Solutions………………………………… 11 Ecolab Healthcare……………………………………………… 8 Welmed, Inc.……………………………………………………… 23

ENDOSCOPY CIVCO Medical Solutions………………………………… 11 Cygnus Medical………………………………………………… BC Healthmark Industries Company, Inc.……………17 MD Technologies Inc.……………………………………… 20 Ruhof Corporation…………………………………………… 2-3 Welmed, Inc.……………………………………………………… 23

CIVCO Medical Solutions………………………………… 11 Cygnus Medical………………………………………………… BC Encompass Group…………………………………………… 49 Healthmark Industries Company, Inc.……………17 MD Technologies Inc.……………………………………… 20 Ruhof Corporation…………………………………………… 2-3 SIPS Consults………………………………………………………15 TBJ Incorporated………………………………………………… 4

INSTRUMENT STORAGE/TRANSPORT CIVCO Medical Solutions………………………………… 11 Cygnus Medical………………………………………………… BC Key Surgical……………………………………………………… 27 Ruhof Corporation…………………………………………… 2-3

SAFETY SINKS Ruhof Corporation…………………………………………… 2-3 TBJ Incorporated………………………………………………… 4

SKIN PREPARATION BD……………………………………………………………………… 25

SMOKE EVACUATION I.C. Medical, INC.………………………………………………… 5

STERILIZATION

Key Surgical……………………………………………………… 27

Cygnus Medical………………………………………………… BC Ecolab Healthcare……………………………………………… 8 Healthmark Industries Company, Inc.……………17 MD Technologies Inc.……………………………………… 20 TBJ Incorporated………………………………………………… 4

LAPAROSCOPY

SURGICAL

INVENTORY CONTROL

Jac-Cell Medical……………………………………………… 53 Innovative Medical Products………………………… 59

MD Technologies Inc.……………………………………… 20 SIPS Consults………………………………………………………15 Welmed, Inc.……………………………………………………… 23

OTHER

SURGICAL INSTRUMENT/ACCESSORIES

AIV Inc.……………………………………………………………… 47

Cygnus Medical………………………………………………… BC C Change Surgical………………………………………………19 Healthmark Industries Company, Inc.……………17 Key Surgical……………………………………………………… 27

OR TABLES/BOOMS/ACCESSORIES

PATIENT MONITORING AIV Inc.……………………………………………………………… 47 Ecolab Healthcare……………………………………………… 8 Jet Medical Electronics Inc………………………………51

PATIENT WARMING Ecolab Healthcare……………………………………………… 8 Encompass Group…………………………………………… 49 Welmed, Inc.……………………………………………………… 23

POSITIONING PRODUCTS

TELEMETRY AIV Inc.……………………………………………………………… 47

TEMPERATURE MANAGEMENT C Change Surgical………………………………………………19 Ecolab Healthcare……………………………………………… 8 Encompass Group…………………………………………… 49

Cygnus Medical………………………………………………… BC Innovative Medical Products………………………… 59

TEST EQUIPMENT

Encompass Group…………………………………………… 49

FLUID MANAGEMENT

REPAIR SERVICES

WASTE MANAGEMENT

Ecolab Healthcare……………………………………………… 8 MD Technologies Inc.……………………………………… 20

Cygnus Medical………………………………………………… BC Jet Medical Electronics Inc………………………………51

FLUID MANAGEMENT SOLUTION

REPROCESSING STATIONS

Welmed, Inc.……………………………………………………… 23

CIVCO Medical Solutions………………………………… 11 MD Technologies Inc.……………………………………… 20 Ruhof Corporation…………………………………………… 2-3

FALL PREVENTION

GENERAL AIV Inc.……………………………………………………………… 47

58

OR TODAY | May 2022

Jac-Cell Medical……………………………………………… 53 MD Technologies Inc.……………………………………… 20 TBJ Incorporated………………………………………………… 4 Welmed, Inc.……………………………………………………… 23

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