OR Today Magazine November 2022

Prepzyme®

ProFormance

Cleaning Veri cation

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.

BUILD IT BETTER

PUBLISHER

John M. Krieg john@mdpublishing.com

VICE PRESIDENT

Kristin Leavoy kristin@mdpublishing.com

EDITOR

John Wallace editor@mdpublishing.com

Karlee Gower

Taylor

Kameryn

ACCOUNT EXECUTIVES

Jayme

Megan Cabot

Emily Hise

DIGITAL

Cindy Galindo

Kennedy Krieg

Kristin

ACCOUNTING

Diane

Linda

Simulation Facility Provides Surgical Training

A new operating room at West Virginia University is pro viding an interactive educational experience to learners of all skill levels – from medical students to surgical faculty.

Located in the WVU Health Sciences David and Jo Ann Shaw Center for Simulation Training and Education for Patient Safety, the new learning environment is open for its first full semester this fall.

STEPS is a state-of-the-art simulation center with fully responsive technology that provides students from all five health sciences schools – dentistry, medicine, nursing, phar macy and public health – with a safe setting to improve their skills before encountering patients in everyday and critical care situations.

The new space is designed and equipped to simulate an actual operating room that would be used by WVU Medi cine surgeons. The space features high-fidelity manikins that mimic human body functions, anesthesia machines, a da Vinci robotic-assisted surgical system that allows procedures to be performed on a manikin or cadaver, and the ability to record sessions for future review and teaching opportunities. Interdisciplinary teams also are able to utilize the space for training that prepares them for interactions they would encounter in a clinical setting.

“This operating room is designed to accommodate learn ers of all abilities,” Dan Summers, director of STEPS, said. “School of Medicine students under the supervision of ex perienced surgical faculty can perform simulated surgeries with the da Vinci robot, students completing their clinical rotation can learn to operate anesthesia and sedate the pa tient manikin in preparation for surgery, and WVU Medi cine residents can practice using both the virtual robotic trainers and the actual robot prior to performing surgery on actual patients.”

“It benefits students and residents in their interactive education through opportunities for hands-on learning,” he added. “The simulation helps them develop skills that they might not experience until much later in their careers and, as a result, improves patient care and safety and health outcomes.”

Since the operating room’s opening, several physicians have trained in the space, providing a great asset for WVU Medicine and the patients they serve. The training environ ment has also allowed WVU Medicine surgeons to provide expert training to individuals outside the health system.

Photo credit (WVU Photo/Aira Burkhart)

American Academy of Nursing Recognizes Trailblazers

The American Academy of Nursing (Academy) will honor Marion E. Broome, Peter Buerhaus, Jennie Chin Hansen, Linda Burnes Bolton, and Bonnie and Mark Barnes with awards for their longstanding contributions to improve care, advance health equity and promote the nursing profession.

“These remarkable individuals have, in their own way, contributed to elevating the voice of the profession in policy, practice, and through purposeful recognition. Their years of servant leadership has been an inspiration to many and all award designees have provided invalu able contributions to the organization,” said Academy President Kenneth R. White, Ph.D., RN, AGACNP, ACHPN, FACHE, FAAN. “It is an honor to award each of them and demonstrate the Academy’s gratitude for their outstanding work. It is a privilege to highlight their dedication to improving health and care for all.”

The President’s Award, which recognizes an indi vidual who has made extraordinary, lifelong contribu tions to improving the health of individuals, families, or communities, will be presented to Marion E. Broome, Ph.D., RN, FAAN, Ruby F. Wilson Professor of Nursing and former Dean for Duke University School of Nurs ing. This is the highest individual achievement award given by the Academy and only awarded when someone has been identified as being truly fitting of the honor. Widely regarded as an expert, scholar, and leader in pediatric nursing research and practice, Broome’s work has been funded by the American Cancer Society, the National Institutes of Health (NIH) and various foun dations for over two decades. Her seminal research developed and tested interventions designed to assist children to cope with acute and chronic pain, review

informed consent and assent for children in research, investigate research misconduct in clinical trials and, most recently, Broome has considered ethical dilemmas in publishing and leadership of nurse executives.

Peter Buerhaus, Ph. D., RN, FAANP(h), FAAN, Professor of Nursing and Director of the Center for In terdisciplinary Health Workforce Studies at the College of Nursing, Montana State University, will be presented with this Academy’s Civitas Award. The award rec ognizes an individual who exemplifies extraordinary dedication to excellence in promoting quality care.

The Health Care Leader Award, created in 2008 to recognize an influential national leader dedicated to improving the health of the nation through contribu tions to organizational excellence, will be given to Jen nie Chin Hansen, DNS(h), MSN, RN, FAAN, immedi ate past CEO of the American Geriatrics Society and former president of AARP.

The Academy will present Linda Burnes Bolton, DrPH, RN, FAAN, Chief Nursing Officer Emeritus, Ce dars Sinai, with the Lifetime Legacy Award. Created in 2019, this award recognizes an extraordinary individual who has dedicated their life to advocating for positive health system changes.

Bonnie Barnes, FAAN, and Mark Barnes, FAAN, co-founders and leaders within the DAISY Foundation, will be presented with the Outstanding Leadership Award. This distinction recognizes Honorary Fellows of the Academy for exemplary service and perseverance as a champion of the nursing profession. The DAISY Foundation and DAISY Award for Extraordinary Nurses was created to recognize and honor the compassionate care nurses provide every day to the patients they serve.

Stryker Launches New Gamma4 Hip Fracture Nailing System

Stryker has launched the Gamma4 System. The newest Gamma System will provide surgeons with the next generation of Stryker’s intramedullary nailing system.

“Since 2004, the Gamma3 System has been the proven work horse of our Trauma business,” said Eric Tamweber, vice president and general manager, Stryker’s Trauma business unit. “But we aren’t proven because we have a legacy; we have a legacy because we are proven. That’s why we’re so excited to introduce Gamma4 – an enhanced, modern product that is designed to fulfill our customers’ hip fracture needs.”

The Gamma4 System is indicated for the treatment of stable and unstable fractures as well as for stabilization of bones and correction of bone deformities in the intracapsular, trochan teric, subtrochanteric and shaft regions of the femur (including osteoporotic and osteopenic bone). The system features:

• Precision Pin: With the Precision Pin, the potential for

INSIGHTS

news & notes

skiving is reduced by 66% compared to a standard 03.2 k-wire.

• A redefined nail design: The SOMA-designed nail fea tures length-dependent RoC, a shortened proximal body and a chamfered distal tip with a pre-inserted set screw.

• An integrated instrument platform: The streamlined portfolio of all Stryker nails now works off the existing IMN Basic set.

“Our design team spent the last decade working to under stand how we could enhance the Gamma System based on surgeon experience and feedback,” said James Maxey, M.D., or thopaedic surgeon and a design surgeon for Gamma4. “Our goal when designing the Gamma4 system was to make it easier for the surgeon – and better for the patient. Being one of the most commonly used devices to repair a hip fracture, I’m confident that we met our goal of reshaping patient hip fracture care for many years to come.”

Olympus Announces EndoClot Options

Olympus will distribute EndoClot Polysaccharide Hemostatic Spray and EndoClot Submucosal Injection Solution, two im portant products developed by EndoClot Plus Inc. (EPI), which joined with Olympus in a U.S. distribution agreement earlier in the year.

Both products are based on the EndoClot Absorbable Modified Polymer (AMP) technology. The starch-derived AMP technology has demonstrated an excellent safety profile, accord ing to a news release. The EndoClot AMP particles work by absorbing water from blood. The dehydration process causes a high concentration of platelets, red blood cells and coagulation proteins, which helps accelerate the body’s clotting cascade, the release adds. AMP particles are biocompatible, bioabsorbable, non-pyrogenic, starch derived and contain no animal or human components.

“Anything we can do to potentially eliminate secondary procedures with some of these more complex cases is important to our practice,” said Kenneth H. Park, MD, assistant professor of medicine at Cedars-Sinai Medical Center. “We see great advan tage in being able to identify the bleed and address it at the same time.”

The EndoClot PHS System enables physicians to apply an advanced powder hemostat during a procedure using controlled, consistent air pressure through a portable air compressor. Used for hemostasis of nonvariceal gastrointestinal bleeding, excluding Forrest Ia classification of bleeding, the EndoClot PHS System is indicated for use in combination with other conventional techniques, like clipping, for large and diffuse bleeds, such as those occurring in peptic ulcers, post-biopsy, polypectomy, tumor

bleeding, as well as post-EMR and ESD and allows for easy irrigation with water during procedures. It provides control of delivery and anti-reflux capability through the applicator design, which can prevent occlusion and treat hard-to-reach bleeds. It also features an air compressor of small, portable design and provides consistent air pressure to propel powder to the bleeding site, while helping prevent the white-out effect common with CO2 propellant; and helps accelerate the body’s clotting cascade: AMP particles work by absorbing water from blood, causing a high concentration of platelets, red blood cells and coagulation proteins.

Performing hemostasis within the GI tract is a technically demanding procedure and use of EndoClot PHS and associated devices may result in patient injury including but not limited to inflammatory reaction, bowel rupture and air embolism.

The EndoClot SIS System is intended for use in gastrointesti nal endoscopic procedures for submucosal lift of polyps, adeno mas, early-stage cancers or other gastrointestinal mucosal lesions, prior to excision with a snare or endoscopic device.

Key benefits of the EndoClot SIS solution include a longlasting, higher lift that may create significant mucosal separation allowing for easier dissection; accurate delivery to the targeted area owing to the unique spiral syringe design; and a lack of residual artifacts that may cause abnormalities during pathologi cal investigations.

Use of a lifting agent during EMR/ESD/POEM and difficult polypectomy and the associated devices may result in patient injury, bleeding and/or perforation.

Children’s Healthcare of Atlanta Marks Major Milestone

Children’s Healthcare of Atlanta announced construc tion on Arthur M. Blank Hospital has now reached its highest point during a topping out ceremony, which recognized more than 1,500 dedicated construction workers.

The event featured speeches by Children’s CEO Donna Hyland, hospital namesake Arthur Blank, and Lex Stolle, a Children’s patient and one of the honor ary construction managers for Children’s Healthcare of Atlanta.

“The demand for pediatric specialized care is greater than ever before and the number of patients Children’s treats each year continues to grow,” said Hyland. “As such, Children’s is not just building a hospital. We are working together at every level to expand our reach, improve the patient family experience, support research efforts and transform pediatric health care. Today’s top ping out ceremony reflects our commitment to staying one step ahead so that we can continue to strive to pro

vide the best, most advanced pediatric care possible.”

Construction on Arthur M. Blank Hospital began in February 2020. The entire North Druid Hills Campus includes the hospital, the Center for Advanced Pediat rics, support buildings, and plans for more than 20 acres of greenspace and walking trails.

The 1.5 million-square-foot hospital, slated to open in 2025, will be located at the northeastern corner of North Druid Hills and I-85 in Brookhaven. Designed to take advantage of research-proven healing views of na ture, Arthur M. Blank Hospital will include one tower with two patient wings and additional operating rooms, specialty beds and diagnostic equipment to meet antici pated patient needs. There also will be space for clinical research, clinical trials and overall patient care.

To learn more about Arthur M. Blank Hospital and the Never Settle Campaign, visit choa.org/give.

The

Commission Releases Sentinel Event Data

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Are Your Case Carts Putting Patients at Risk?

By David Taylor III, MSN, RN, CNOR

S terile processing-related functions and processes are coming under greater surveyor and auditing scrutiny, and case carts are just one aspect drawing more frequent attention. In fact, hospitals and other health care organizations are being cited more frequently in regulatory audits as they and other regulatory bodies observe the use and flow of case carts.1

Case carts may appear to be just another piece of equipment, but they are crucial for protecting and transporting instrumentation, medi cal equipment and supplies to the operating room (OR) and other pro cedural areas safely and in a timely manner. A well-constructed plan and an orchestrated series of activities coordinated by sterile processing (SP) professionals and their proce dural partners is necessary to ensure case carts are managed properly, safely and consistently to support customer needs; however, many health care organizations aren’t giving their case carts the time and attention they deserve.

Achieving reliable instrument re processing requires striking the right balance among cost, productivity and safety, and case cart management strategies play a critical role in the process. Interdepartmental coop

eration is required, and case carts present one of the most proven ways to simplify processes and ensure that devices are transported safely and in accordance with standards, best prac tices and policies and procedures.

Follow the right path

tion-free during transport to user areas. Contents must be well secured to prevent shifting and possible dam age. Once procedures are completed, the instruments and equipment are transported back to the SPD using a dedicated “dirty pathway.”

Although clean and dirty path ways between the SPD and proce dural areas should remain separate, many organizations fail to design a clean or dirty (contaminated) path way, or they have expanded their operations, but without devising a proper plan and flow to allow for this separation. In my consulting experience, I have witnessed many organizations transporting case carts through public hallways, corridors and elevators, for example. The re sult is a heightened risk to case carts and their contents, which then cre ates an increased risk to the patient.

Cart casters require ongoing inspection, cleaning and maintenance to ensure smooth operation and prevent buildup and debris.

Case carts begin their journey in a restricted area of the SP department (SPD). Once disinfected, they travel from one restricted area to another by following a clean pathway, either laterally or vertically (elevator) before being used in patient care. Case cart cleanliness is essential for ensuring patient-ready instruments remain protected and contamina

When clean thoroughfares (lateral or vertical) do not exist, case carts are often staged in public spaces before being transported to their destination. If the SPD is located in the basement, case carts can often be found unattended, parked along dirty corridors with their contents at risk for contamination, damage or even theft.

Cleaning, maintenance critical Dust, sutures, mop strings and other dirt and debris can easily collect on carts and their casters; therefore,

INDUSTRY INSIGHTS

proper cleaning and inspection of case carts after each transport and use are extremely important. When case carts are staged in dirty areas and transported through public areas, they should be cleaned (wiped down) with an appropriate agent prior to entering a restricted (clean) procedural area.

Aside from possible contamina tion and infection-related implica tions, poorly maintained case carts can impede proper function, leading to compromised cart contents and injuries to employees and others who may be near the carts during transport and stowing. When kept in sterile storage, some key param

and consist of a minimum of four air exchanges per hour. 2-3 If the SPD is staging case carts stocked with sterile instrumentation and supplies in a public hallway, however, the ques tion becomes, “Who is validating temperature, humidity, positive or negative pressure and air exchange rates?”

To keep case carts in good and safe working condition, the following key inspection points and focus areas should be prioritized:

• Ensure case cart(s) are large enough to properly contain contents (cramming instru ments or piling/stacking them can cause damage to items).

• Confirm doors, latches, lock ing mechanisms, casters and handles function properly and are not damaged. Any cart features that are not in good working condition can create opportunities for injury and content damage.

• Avoid overloading or excessive weight on shelves.

• Maintain the security of sealed carts.

• Follow proper infection preven tion procedures.

Conclusion

Avoid overloading carts and stacking or teetering trays, which can damage packaging, increase contamination risks and jeopardize employee safety during transport.

eters must also be met. Standard temperature of the area should range from 72 to 78 degrees F, and relative humidity should not top 60%. Addi tionally, the space and adjacent areas must have positively air pressure

Maintaining case carts before, dur ing and after use is critical to safe patient care. Fortunately, health care organizations can adopt measures and practices to prevent incidents of contaminated instruments reaching end users and patients if they invest a little effort into their processes

David Taylor III, MSN, RN, CNOR, is an independent hospital and ambulatory surgery center consultant and the prin

Shelves should rest evenly to prevent packages and other contents from shift ing or falling during transport.

cipal of Resolute Advisory Group LLC, in San Antonio, Texas. He has served as an HSPA contributing author since 2019.

References

1. https://www.hpnonline.com/sterile-pro cessing/article/13000988/maintainingcase-cart-containers-critical-for-safetysuccess

2. https://www.jointcommission. org/standards/standard-faqs/ ambulatory/environment-of-careec/000001275/#:~:text=Minimum%20 total%20air%20exchange%204,or%20 22%20to%2026%20C

3. https://www.evolvedsterileprocessing. com/post/2019/11/10/sterile-storage-anassessment-of-temperature-and-humidi ty-conditions

ST98: New Standard in Medical Device Cleaning Spotlights ‘Clean’ for Manufacturers

W hen it comes to processing multi-use medical devices, sterilization often gets the splashy headlines, but cleaning is just as – if not more –important, and with ANSI/AAMI ST98:2022, cleaning is the star.

The new standard, which formalizes requirements for cleaning validation methods, not only advances under standing of and conformance with cleaning best practices but has the po tential to have an impact on the design and development of medical devices for years to come.

Many of the core ideas be hind ANSI/AAMI ST98:2022, Clean ing validation of health care prod ucts—Requirements for development and validation of a cleaning process for medical devices have been part of important discussions since 2014, when thought leaders were working to revise ISO 17664 and TIR12. These documents cover information to be provided by manufacturers for the processing of re-sterilizable medi cal devices and compliment the new cleaning standard.

Nupur Jain, director of sterility assurance and reprocessing at Intuitive Surgical and co-chair of the AAMI Cleaning of Reusable Medical Devices Working Group (AAMI ST-WG93) noted how the standard builds upon previous guidance from AAMI, FDA and other organizations, as well as its close ties to a technical information report (TIR) used by manufacturers, AAMI TIR30.

“AAMI TIR30 and ANSI/AAMI ST98 have two main differences. The first difference is related to the scope of the documents: AAMI TIR30 covers reusable medical devices, while ANSI/ AAMI ST98 has a broader range and applies to devices that require processing before clinical use per the Spaulding scale, including single-use devices that require processing by the health care facility prior to use,” Jain explained. “The other key difference is that instead of only providing an over view of cleaning test methods, ANIS/ AAMI ST98 specifies requirements for cleaning validations.”

“ANSI/AAMI ST98 is built on a lot of other activities, and [a lot of the same] people have been involved in

that, so it is evolutionary,” said Ralph J. Basile, vice president of marketing and regulatory affairs for Healthmark Industries. “But then it is also revolu tionary in the sense that it is really the first document, globally … that gives requirements for device manufacturers as far as what they need to do to vali date their cleaning [and ensure] their cleaning instructions actually produce a clean device.”

“Where it’s unique is in specif ics for the design of medical devices, and that’s an area that has been very lacking in consistency and scientific content for a long time,” added Dr. Gerald McDonnell, senior director of microbiological quality and steril ity assurance for Johnson & Johnson. “This gives us the opportunity to have the same opinion [on cleaning] across multiple companies across multiple parts of the world.”

ANSI/AAMI ST98 has two sec tions: normative and informative. The normative section (the main text of the standard) lists the requirements for cleaning validations. The informa tive content found in the annexes provides guidance on applying the

normative requirements. While the normative content provides impor tant and detailed information on the cleaning validation and what test methods are most suitable for various types of medical devices, the informative content helps guide manufacturers on providing end us ers with validated processes.

Currently, processing and steril ization professionals are burdened by budgetary constraints – hos pitals are more likely to devote extra dollars to new surgical suites, which generate revenue, rather than cleaning and sterilization depart ments, which don’t. Another consideration is time – professionals have to process similar devices from numerous manufacturers, each of whom can provide a very different set of Instructions For Use (IFUs). And as devices have become more complicated, having numerous IFUs has become an even bigger burden, Basile said.

“The validation testing that we’re doing needs to really reflect what’s happening at the health care facil ity so that the instructions device manufacturers give actually result in a clean device,” Basile added.

Cleaning vs. Sterilization

In fact, McDonnell explained that many of the contamination prob lems the medical device industry has experienced in recent years has been due to issues with clean ing rather than with sterilization or disinfection – words that are often used interchangeably but that, at least in the field of medical devices, have very different meanings. While sterilization can kill many varieties of live microbes, dead or non-living things, such as prions, can be just as dangerous, and they aren’t always vulnerable to standard sterilization methods.

Once ANSI/AAMI ST98 gains a critical mass of industry adoption, Basile and McDonnell expect to see device manufacturers take things even further. It is anticipated that manufacturers will consider cleaning from the start, building cleanability into their designs for new or up dated devices. They also suggest that training – and, potentially, certifica tion – of processing professionals will become more stringent.

“I think there’s going to be a trend definitely toward designing devices that are easier to clean, and I think you’ll also see some innova tions in who cleans them,” McDon nell said. “I think you’ll see that it is a talent and a professional thing to make sure devices get repro cessed correctly. It’s not cleaning dishes. People need to be trained. They need to be competent. And in the past, it wasn’t always that way. We still argue in the United States [about whether] you need to be cer tified to work in those departments.”

There’s also optimism that ANSI/AAMI ST98 will help inspire a similar international standard, helping companies in a global mar ket further streamline their cleaning, validation, and instruction processes, and encouraging them to continue to push for stronger cleaning prac tices in health care facilities around the world.

“I’m looking forward to having a little bit more clarity on what’s required and what is considered acceptable in the design of devices, and that will also help in the regula tory approval of devices,” McDon nell said. “I think that will overall have an impact of streamlining the development process and having more consistent products in the marketplace that would be safer for patient use.”

Common Concerns

Highlight Need for Unity

By Bill Prentice

N o matter the setting, health care providers across the country are confronting several common concerns that threaten our ability to provide highquality care to our patients, and in some cases, to continue to provide care at all.

Economists and health care profession als agree that most of these problems are not likely to go away soon. Our best chance to turn these situations around is for everyone in health care to come together to design and support multifac eted, long-term solutions and participate in public-private partnerships to make them work.

Let’s consider what we’re up against.

Workforce Shortages

Few industries escaped the workforce shortages that occurred after the pandemic was declared, but health care was one of those hit hardest by the Great Resignation at a time when the need for top-quality staff was at its height. We all watched salaries for staff and traveling nurses soar to new levels as competition for skilled health care professionals intensified.

In December 2021, an ASCA survey of the ASC community showed that 77% of respondents were experiencing nursing or staffing shortages. A followup survey conducted this June suggests the situation has improved modestly as 51% of participants reported average staff turnover rates in the last year of 5% or less. Meanwhile, most of the survey participants reported increasing aver age hourly rates for clinical personnel between 2021 and 2022.

Projections of future physician and nursing shortages that have circulated for years compound the problem.

Drug Shortages, Escalating Costs and Sup ply Chain Challenges

Drug shortages, sourcing challenges for supplies and rising costs are not new in health care, but like we experienced with workforce shortages, the pandemic in tensified these concerns. Again, no one is predicting a resolution to these problems anytime soon.

More than 99% of those who partici pated in an American Society of HealthSystem Pharmacists (ASHP) member survey back in March reported being affected by shortages of critical drugs. While most who responded to that sur vey work in hospital settings, members of the ASC community also frequently report difficulty getting the drugs they need for their patients.

Meanwhile, during August, the Bureau of Labor Statistics reported an 8.5 percent increase from July 2021 to July 2022 in the price of common con sumer goods. As I write this, Medicare is projecting a 3.1% increase in the hospital market basket for 2023 (and using that figure as the basis for proposing an overall payment update of just 2.7 percent for ASCs and hospital outpatient depart ments in 2023), but several professional associations are saying that figure comes nowhere near the amount needed to cover the increased costs hospitals and other health care providers will need to absorb next year.

Cybersecurity

As individual health care entities con tinually update their systems to stay at

least one step ahead of the newest secu rity threats, the risks involved continue to escalate.

For example, in the first half of 2022, the Office for Civil Rights reported that health care organizations across the coun try posted 337 breaches of protected health information (PHI) affecting 500 or more individuals. Consistent with the past, unauthorized access or hacking caused the overwhelming majority of those breaches — 95 percent in the first half of 2022.

Meanwhile, a ransomware report in a mid-year update of the “SonicWall Cyber Threat Report” issued by Californiabased network security company Son icWall indicates that while ransomware attacks around the world in the first half of 2022 decreased from 2021 levels, they remained far above pre-pandemic levels. In addition, the health care industry saw a triple-digit increase of 328 percent. Kroll, a corporate consulting firm that manages cyber risks for its clients, recent ly reported a 90% increase in the number of health care organizations targeted by ransomware in Q2 2022 compared to Q1 levels.

An August 2022 article in The Hill raises concerns that countries like China, Russia, Iran and North Korea have been linked to significant cyberat tacks over time or the ransom pay ments made in response.

Solutions

The list that follows is far from com plete but provides a sample of solutions that have been proposed and the work needed to convert those plans into action.

Since concerns about shortages of physicians, nurses and skilled staff are

nothing new, organizations like the American Nurses Association and the Association of American Medical Col leges already have proposed solutions for encouraging students to enroll in these career training programs. Their ideas deserve even greater attention and support today as need continues to intensify. We have also seen a proposal to encourage foreign citizens training for medical careers in the U.S. to remain in this country upon graduation. That plan would require congressional action to be put in place.

One of the proposals for building and sustaining a reliable supply chain is strong public-private partnerships that incor porate visibility, coordination, agility and trust. Others coming out of ASHP and the American Medical Association, the American Society of Anesthesiologists, the Association for Clinical Oncology

• incentivizing the development of advanced manufacturing technol ogy for critical drugs and active pharmaceutical ingredients;

• improving the function and com position of the Strategic National Stockpile (SNS);

• engaging pharmacists, physicians, other clinicians and supply chain experts to develop processes for maintaining and refreshing prod ucts in the SNS;

• incentivizing quality and resilience; and

• replicating requests for critical drug manufacturing transparency and oversight for medical devices and ancillary supplies, such as personal protective equipment.

In a letter sent to U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra in August, Sen. Angus King (I-Maine) and Rep. Mike

Gallagher (R-Wis.) urged the Biden Administration to scale up its investment in protecting the health care and public health sector from the growing number of cyber threats. A bipartisan bill intro duced in Congress in March could help. The Healthcare Cybersecurity Act, cosponsored by Sens. Jacky Rosen (D-Nev.) and Bill Cassidy (R-La.), would require that the Cybersecurity and Infrastructure Security Agency (CISA) collaborate with HHS to improve cybersecurity standards in the health care and public health sec tor. It would also require both agencies to share information with the private sector to increase cyber resilience.

If we act together now, we can elimi nate these concerns and improve the care we offer our patients.

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

Opportunity in Perioperative Nurse Hiring

By James X. Stobinski, Ph.D., RN, CNOR, CNAMB, CSSM(E)

A s the chief executive officer of the Competency and Credentialing Institute (CCI), I frequently interact with nurse leaders and often our conversations turn to staffing challenges. Most of the perioperative leaders I have spoken with have said that they are having difficulty hiring the needed staff including perioperative nurses and surgical technologists. These anecdotal reports are reinforced by a 2022 survey (Saver, 2022). Saver reports that surgical volume has rebounded to pre-pandemic levels or higher for many operating rooms but staffing challenges are restricting the work of surgery.

A confluence of events has brought us to this point. The pandemic has likely pushed many experienced nurses to leave the profession and many perioperative nurses were among that group. Although the exact demographics of the periopera tive specialty are not well known, we have anecdotal evidence at CCI based on the record number of certified nurses who have recently retired their credentials. Our evidence is that experienced periopera tive nurses for the first time in their career were furloughed or lost employment entirely during the pandemic. In addition, other seasoned perioperative nurses, who fell into high-risk categories based on age, chose to retire versus providing care for COVID-19 patients in other units such as the ICU as part of team nursing.

From the 2020 National Nursing Workforce Survey we know that there may be as many as 470,000 nurses in the United States that have perioperative nursing as a significant part of their work

either in their primary duties or as their secondary specialty. (Stobinski, Maio & Homme, 2021, p. 22). This is 11.2% of the active American nursing workforce and includes perioperative and perianes thesia nurses (Smiley et al, 2021). With the rebound in surgical volume a record number of nurses are being hired into the OR and there are thousands of nurses in orientation to the specialty including recent graduates. This hiring and orienta tion activity is a challenge, but CCI believes it is also an opportunity.

A recent article in Outpatient Surgery detailed the collaboration between Chamberlain University and AORN for a perioperative nursing course for prelicensure students (Paone, 2022). There is also a smattering of senior practicum ex periences available. In a similar vein, the CCI nurses teach BSN pre-licensure stu dents at Edgewood College in Madison Wisconsin. All these approaches increase exposure to perioperative nursing, but we do not know the long-term impact of any of these approaches. The current staffing shortfalls present an opportunity to evaluate and refine the approaches listed above.

There is an opportunity for additional research into how perioperative nurses enter the specialty and acquire skill over a career. Few studies have attempted to study the effectiveness of orientation programs to perioperative nursing. Many facilities, perhaps one-third of all orienta tion programs used, are developed by the facility (Stobinski et al. p. 23). At CCI, we believe these diverse programs should be studied and compared and the evidence used to continuously strengthen and refine our orientation methods. We also believe that the effectiveness of an orientation program can also be measured by the

competency of the graduates.

I have described some complex research challenges in this column which represent an opportunity to re-shape and strengthen the perioperative nursing specialty. Perioperative nursing is staring down some great challenges at present. The current surgical staffing issues are among the most severe I have ever seen but I am confident that perioperative nursing will meet this challenge. I also believe there are opportunities present in these trials for those willing to try new approaches, to do the research and gather the evidence to support our specialty.

- James X. Stobinski, Ph.D., RN, CNOR, CNAMB, CSSM(E), is CEO of the Compe tency and Credentialing Institute (CCI).

References:

1. Paone, J. (2022) Help is on the way. Outpa tient Surgery Magazine.

2. Saver, S. (2022). Survey: Surgical volume returns for many ORs, but staff shortages remain. OR Manager, (38)9. (Pp 1, 5-9).

3. Smiley, RA, Ruttinger, C, Oliveira, CM, Hudson, LR, Allgeyer, R, Reneau, KA, Silvestre, JH, Alexander, M. (2021). The 2020 National Nursing Workforce Survey, Journal of Nursing Regulation, (12)1, Supplement, (S1-S96) ISSN 2155-8256, https://doi.org/10.1016/S21558256(21)00027-2.

4. Stobinski, JX, Maio, S and Homme, C (2022). Results of a competency assessment study of OR nurses in the US. OR Manager, 38(6). 2225. Accessed: June 21st 2022 at: https://www. nxtbook.com/accessintelligence/ORManager/ or-manager-june-2022/index.php#/p/24

INDUSTRY INSIGHTS

Webinar Explores Sterile Packaging in the OR

report

T he recent OR Today webinar “An OR’s Guide to Sterile Packaging” was presented by Clinical Education Specialist Malinda Elammari, CST, CSPM, CSPDT, CFER, CSIS, CRCST, CIS, CHL, CER, CLSSGB, and Clinical Education Coordinator Kevin Anderson, BSN, RN, CNOR, CSSM, CRCST, CHL, CIS, CER, from Healthmark Industries. It was eligible for 1 CE credit. OR Today is approved and licensed to be a Continuing Education Provider with the California Board of Registered Nurses, License #16623.

The webinar, which was sponsored by Healthmark Industries, focused on the key factors pertaining to sterile packaging. It covered sterile packaging terminology and discussed the main differences between containment devices. The presenters also reviewed transport and placement considerations for sterile items. The webinar also demonstrated key inspection points for sterile barriers in the operating room.

It was a popular webinar with 218 attendees. A post-webinar survey provided attendees an opportunity to share feedback.

“It was a fantastic webinar! I really enjoyed the delivery and the two presenters. The female presenter was a rockstar! This was one of the most engaging webinars I have seen in a while and that had everything to do with using real-life scenarios and situations that we all have encountered,” said Eddy Wenzel, department chair-surgical technology, central service and imaging science, Ivy Tech Community College.

“Excellent content, applies to all levels of knowledge,” said Phyllis Burton, retired RN.

“I loved it. Very informative and explained the ratio nale behind all of the pictures,” Kristen Gomez, Infection Prevention RN.

For more information, visit ORTodaywebinars.live.

Thank you to our sponsor

IN THE OR market analysis

Cleaning Markets Expected to Soar

Staff report

O R Today looks at washers and disinfectants in this month’s product focus feature.

Reports from research organizations predict continued growth in the medical device cleaning market as well as in the surface disinfectant market.

According to a comprehensive research report by Market Research Future (MRFR), the medical device cleaning market is projected to cross $4.1 billion by 2026. This predicted growth would result from a compound annual growth rate (CAGR) of 7.2%.

After a specific use, medical instru ments must be sterile. This is done for the purpose of ensuring patient safety and preventing infections at the wound and incision sites. Cleaning surgical tools is also a more important and critical chore than cleaning non-medical gadgets. Surgical equipment is contaminated with blood, organic materials, pus, tissue and other contaminants that could spread infection to others if reused. As a result, medical device cleaning agents are used to clean and disinfect medical instruments.

The medical device cleaning market is expected to grow significantly over the forecast period, owing to factors such as an increase in the number of surgical procedures, an increase in the number of COVID-19 patients, an increase in the number of private and public hospitals, and an increase in the availability of

disinfectants for surgical products, among others. The strong need for developing competitors to enter the disinfection in dustry is projected to be fueled by the ris ing demand for disinfectants. This reduces the risk of a new player entering the global medical device cleaning industry.

A growing number of patients with chronic diseases, a growing geriatric population, a growing number of private and public hospitals, a growing number of regulatory requirements and compliance, a growing number of surgical procedures, growing government investments to im prove primary health care infrastructure and rising patient health care expenditure are all factors expected to impact the market.

Grand View Research predicts that the global medical device cleaning market size was valued at $19.5 billion in 2021 and is expected to expand at a CAGR of 10.5% from 2022 to 2030.

According to a market research report published by Meticulous Research, the surface disinfectants market is expected to grow at a CAGR of 7.5% from 2022 to reach $10.1 billion by 2029.

Surface disinfectants are used in the process of disinfection to kill or inactivate microorganisms in order to prevent their transmission. It is especially important in health care settings due to the high prevalence of healthcare-associated infec tions (HAIs). Surface disinfectants are available in various formulations such as liquids, wipes or sprays. To follow regula

tory compliance, the routine disinfection of facilities is followed by many indus tries, especially the pharmaceutical and biopharmaceutical industry. Moreover, surface disinfectants are also gaining more popularity in households and residential settings owing to the outbreak of the COVID-19 pandemic.

Rising awareness about sanitization, health, and safety; increasing prevalence of chronic diseases; increasing number of surgeries in health care facilities; increas ing number of health clubs and gyms; expanding tourism industry globally; and the recent outbreak of infectious diseases are the major factors driving the overall surface disinfectants market. Furthermore, introducing novel disinfection products and untapped markets in emerging economies provides significant growth op portunities for companies operating in the surface disinfectants market. Increasing standard of living, rising economy, health care awareness, medical tourism, growth in disposable income and the prevalence of infectious diseases are some of the major factors garnering the attention of key players in surface disinfectants market towards developing economies.

However, lack of understanding to use standard disinfection practices by end-users, availability of alternative products and technologies, and envi ronmental and health hazards associ ated with the use of disinfectants are expected to hamper the growth of this market to a certain degree.

PDI

Sani-24 disinfectants

Sani-24 Germicidal Disposable Wipe is the first and only EPA-registered disinfectant featuring Con tinuously Active Disinfection (CAD), a technology providing protection against a wide array of patho genic organisms within a one-minute contact time. With CAD, Sani-24 wipe leaves a protective layer of disinfectant on the surface as it dries. This antimicro bial shield will continuously kill ESKAPE pathogensresponsible for over 40 percent of HAIs in the health care environment – for up to 24 hours.

SC Johnson Professional

Alcare Plus Foamed Antiseptic Handrub

Alcare Plus Foamed Antiseptic Handrub is a wa terless surgical scrub designed for use in health care settings. The alcohol-based, unique foam mousse has fast-acting, broad-spectrum efficacy with no rinsing required. The rich, thick foam mousse easily rubs across hands, providing the user with good control of the product to help prevent dripping and splashing. Its moisturizing formula is also clinically proven to moisturize skin for up to two hours after use. Alcare Plus Foamed Antiseptic Handrub is Chlorohexidine Gluconate (CHG) compatible, perfume and dye-free, making it a suitable choice for a hand sanitizer or surgical scrub in health care.

product

Belimed Protect Pretreatment Foamer

The Belimed Protect Pretreatment Foamer is de signed to easily and ergonomically apply Belimed Protect Pretreatment, resulting in better compliance for pretreating surgical instruments. The thick foam created from the Pretreatment Foamer provides tri ple the coverage of manual spraying and minimizes particulate emissions into the surrounding environ ment. The Pretreatment Foamer includes a unique cart for mobility and two wands, one for general trays and one for cannulated instruments. The cart design holds 1 gallon or 2.5 gallon container sizes, which is more cost effective and environmentally friendly than traditional manual spray bottles.

CIVCO ASTRA TEE and ASTRA VR Automated Reprocessors

The ASTRA TEE and ASTRA VR Automated Repro cessors are compatible with leading transesopha geal (TEE), transvaginal and transrectal ultrasound probes (including biplane probes up to 16 inches).

With the ability to disinfect up to two probes at once, taking an average of 10-16 minutes to com plete with no sleep mode, ASTRA allows for fast and simplified probe turnaround. ASTRA is compat ible with reusable, industry-leading disinfectants to help reduce long-term operating costs compared to expensive, single-use bottles. The automated data logging, consumable tracking and easy-to-follow prompts can help you stay compliant with The Joint Commission standards.

For more information, visit civco.com.

MicroCare Medical Infection Prevention ProEZ Gel

ProEZ Gel is applied to soiled instruments and reusable devices as soon as possible after treatment and before transport to the final cleaning or central sterile processing area. Gentle, neutral pH ProEZ Gel is tested for broad material compatibility and actively protects delicate instrumentation by dissolving corrosive blood soils during transport before damage can occur in vulnerable jointed areas. ProEZ Gel is tested and validated to sustain moisture, continue soil breakdown and protect instrumentation up to 72 hours holding time. Easy to apply, it has a green tint to help monitor coverage and compliance with pretreatment protocols.

Palmero Health DisCide Ultra Disinfectant

With intermediate level DisCide Ultra, surface disin fectant and decontaminant cleaner, you can ac celerate the way you disinfect clinical settings. In just 60 seconds, DisCide Ultra is effective against TB, viruses (HBV, HCV, RSV, HIV-1), bacteria (MRSA, VRE, E. coli) and fungi (C. albicans). Specifically formulated to resist evaporation, it’s non-corrosive, non-staining and leaves no residue. Plus, it meets OSHA’s blood-borne pathogen standard. Ready-touse for the ultimate in convenience, DisCide Ultra is available in identical formulations in both spray and towelette formats to ensure efficacy when liquid and towelettes are used in tandem. DisCide to be sure with fast acting DisCide Ultra.

Leech Therapy

M edicinal leech therapy, also known as hirudotherapy,

has a long tradition but fell out of favor, because scientists proved that blood loss was not therapeutic. The popular use of leeches did not return until development of techniques for microvascular surgery.

Many microvascular operations failed because of venous congestion or inadequate blood drainage from the reattached or transplanted tissue. Unless this congestion is relieved, blood clots form and cut off blood flow into reattached tissue, with tis sue eventually dying. Leeches raised for medicinal purposes can help with decreasing this congestion until new venous drainage is established. This educational activity may update your knowledge about leech therapy and also help you care for patients using this treatment.

Section 2: Leech Therapy

You watch as the thin, black, worm like creature crawls around and then attaches itself to your patient’s skin. The animal begins to pulsate slightly

and grows larger before your eyes. You are not trapped in a scene from a science fiction or horror film but are participating as a healthcare pro fessional in an effective therapy that uses leeches to enhance blood flow at your patient’s operative site.

You might be caring for Caitlin, a 3-year-old who had two fingers traumatically amputated when she and her 5-year-old brother decided to play with their father’s electric saw. Although Caitlin’s fingers were successfully reattached, they became edematous and purple postopera tively. Or you might be assigned to 67-year-old John, who had a radical neck dissection for cancer that re quired a muscle graft from his chest. Within 12 hours, the muscle flap’s color turned from a deep pink to a dark blue. The pulse through this graft, which initially had a moderate quality, faded until it was only faintly detectable by doppler.

Both patients may benefit from leech therapy. This treatment uses live leeches to draw out pooled venous blood from a reattached digit or a muscle-flap graft until an adequate venous flow can be re-es

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

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

Goal and Objectives

The goal of this course is to provide nurses with information necessary to care for patients who undergo leech therapy. After taking this course, you should be able to:

• List current clinical applications of leech therapy.

• Describe appropriate nursing interventions for patients receiv ing leech therapy.

• Identify ways to provide the ed ucational and emotional support needed by patients undergoing leech therapy and their families.

tablished. Healthcare professionals of various disciplines play a vital role in the care and handling of the leeches, in the management of the

patients, and in the acceptance of this unusual therapy. This course will help prepare you for the challenge of leech therapy.

From History to Now

Leeches are hermaphroditic, bloodsucking worms. Medicinal leech therapy (MLT), also known as hirudotherapy, extends back for cen turies. Egyptians used leech therapy more than 3,500 years ago (Wollina et al., 2016). Leech treatments were commonly used during the Middle Ages. The word “leech” is derived from the Old English word for “phy sician.” During the 18th and 19th centuries, leeches were used so often that their use was called “leechma nia.” Physicians believed that too much blood caused disease, so they prescribed leeches for anything from headaches to hemorrhoids. In the late 1800s, the practice of leeching fell out of favor, because scientists proved that blood loss was not therapeutic. However, over the past 30 years, more scientific research has been conducted on MLT.

The popular use of leeches did not return until the development of techniques for microvascular surgery during which surgeons were able to stitch small arteries and veins back together under a microscope. Mi crovascular surgery made it possible for surgeons to reattach severed blood vessels and tissue as well as to transplant skin flaps. However, many of these operations failed because of venous congestion or inadequate blood drainage from the reattached or transplanted tissue. Unless this congestion is relieved, blood clots form and cut off blood flow into the reattached tissue, and the tissue even tually dies. In 2004, the U.S. Food and Drug Administration (FDA) cleared the commercial marketing of leeches for medicinal purposes (in skin grafts and reattachment surgery) and de termined that leeches are considered medical devices.

There are over 600 different spe cies of leeches, with 15 classified for medical use (Wollina et al., 2016). The most common leech used for medicinal purposes is the Hirudo medicinalis. This variety of leech is about 10 cm in length and weighs 2 grams. Today, medicinal leech ther apy (MLT) uses leeches grown from special, sterile leech farms and no longer uses leeches found in fresh water ponds and rivers. However, even though medicinal leeches are bred in sterile leech farms and kept under controlled conditions, they are still colonized with bacterial flora. Aeromonas hydrophila, is a gram negative bacteria which lives normal ly in the intestines of the leech and aids in the digestion of blood. It has been reported to cause infection in humans by contamination through the bite of the leech or on the mac erated skin (Hackenberger & Janis, 2019). Prophylactic antibiotics such as fluoroquinolones or sulfamethox azole/ trimethoprim (Bactrim®) are recommended to be used in conjunc tion with leech therapy to prevent infection (Herlin et al, 2017).

Leech saliva is the source of sev eral substances that stimulate wound healing. One of the most common substances is the antithrombin agent hirudin which binds to thrombin to prevent coagulation. Basically, leeches produce hirudin to prevent the host from forming a clot so that they can suction the blood out more easily. It also allows for continued bleeding for several hours after the leech is removed. Serving as a substi tute vein, a leech sucks off the blood before it can clot, thus keeping the tissue healthy until new veins grow — usually in 5 to 6 days (Whitaker et al., 2012).

Indications for Leech Therapy

Leech therapy is now used in both pediatric and adult populations to treat venous congestion, a com plication of plastic and microsurgery

continuing education

(Whitaker et al., 2012). Generally, insurance considers MLT as med ically necessary for these types of conditions (Aetna, 2020):

Venous congestion or venous outflow obstruction

Compromised flaps (tissue with intact blood supply is surgically transferred from one site of body to another)

Replantation (such as digits, ears, degloving injuries or other body parts reattached after traumatic amputation)

Past clinical studies show MLT has a success rate of saving tissue of 78% (Hackenberger & Janis, 2019). Leech therapy has also been used in treating the following conditions (Aetna, 2020; Sig et al., 2017; Wolli na, 2016; Thakur, 2016):

• Pain syndromes

• Osteoarthritis

• Purpura fulminans

• Hematomas

• Epidermal cysts

• Autoimmune disorders

• Skin disorders

• Varicose veins

• Dental conditions

However, further evidence is needed to fully support leech thera py for some of these conditions.

As listed, leeches have been used to provide pain relief. The analgesic action of leeches has been noted in several clinical studies. A narrative review of MLT with varying pain syndromes reported several studies with positive pain outcomes (Koep pen et al., 2014). A randomized controlled trial (RCT) found study groups receiving a single application of leech therapy had better pain re lief when compared to a continuous standard analgesic pain medication in patients with osteoarthritis in the knee. Another RCT study of 90 patients compared the use of leeches applied weekly for 3 weeks to the affected knee to the use of transcu taneous electrical nerve stimulation

education

(TENS) for management of osteoar thritic pain of the knee. Both therapies provided statistically significant re duction in pain scores, suggesting that leech therapy may be an additional modality for pain management (Iskik et al., 2017).

Other clinical studies demonstrated leech therapy improved patients’ pain from chronic epicondylitis, lower back pain, and cancer pain when compared to control groups (Hohmann et al., 2018; Koeppen et al., 2014; Wollina, 2016). Additionally, discomfort ex perienced from swelling was also im proved by leech therapy in conditions such as hematomas and venous stasis. The analgesia of leech therapy is likely attributed to the leech saliva that has anti-inflammatory, anticoagulant, and blood circulating properties.

Medical leech therapy with H. medicinalis is most commonly used to relieve venous congestion. This is often used for compromised pedicle flaps and microvascular free tissue transfer, digital reimplantation, and nipple congestion post breast surgery (Aetna, 2020). For compromised flaps, leech therapy is best used immediate ly after surgery. This is because flaps are known to have decreased survival within 3 hours if venous flow is not established. If venous flow is compro mised around a flap or replant area, the skin becomes cyanotic and cool and hard to the touch. Initial capillary refill time (CRT) should be 1 sec ond or less. However, if this remains untreated and the CRT increases to longer than 3 seconds, the tissue will die. The goal of leech therapy in these cases is for the compromised area to become pink, become warm, and have a CRT of less than 2 seconds. MLT is typically conducted for 4 to 5 days for patients with replants and 6 to 10 days for patients with compromised flaps.

Contraindications and Complications

Leech therapy is, however, not with out complications and is not appro

priate for all patients. It is important to distinguish between venous and arterial insufficiency. When arterial insufficiency is present, tissue may be pale, cool to touch, and capillary refill is longer than 2 seconds or is totally absent. Leech therapy is con traindicated in arterial insufficiency. In venous insufficiency, the tissue may be purplish, engorged, taut, and warm to touch with capillary refill less than 1 second, which is an ap proved indication for leech therapy.

Additional contraindications to medicinal leech therapy include (Pourrahimi et al., 2020):

• Hemophilia

• Anemia

• Leukemia

• Hypotension

• Sepsis

• Hepatobiliary diseases

• HIV infection

• Anticoagulant therapy

• Immunosuppressive therapy

• Pregnancy and/or lactation

One systematic review of 67 papers reporting on 277 cases of leech use found an overall compli cation rate of 21.8% (Whitaker et al., 2012). A recent review found the most commonly reported complication with MLT is a bacte rial infection (51%) (Pourrahimi et al., 2020). The Aeromonas species bacteria is responsible for 88% of leech-associated infections (Hacken berger & Janis, 2019). Antimicrobial susceptibility analysis determined many Aeromonas bacteria are often resistant to amoxicillin/clavulanic acid (Augmentin®) and most sec ond-generation cephalosporins. Third generation cephalosporins (e.g., cef triaxone), sulfamethoxazole/trimeth oprim (SXT), and fluoroquinolone (e.g., ciprofloxacin, levofloxacin) are effective for Aeromonas infections (Pourrahimi et al., 2020). One U.S. study reported 91.5% of patients receiving leech therapy had prophy

lactic antibiotics administered.

Other complications related to leech therapy include allergic reaction (21%), prolonged bleeding (15%), and migration of the leech (8%). Complaints of itching at the bite site is also commonly reported.

Leech Action

Both ends of a leech have suckers that attach jointly to the tissue while feeding. The mouth, located on the anterior end, has three sharp jaws that leave a Y-shaped bite. These jaws could have up to 100 teeth (Wollina, 2016). A leech is an effi cient bloodsucker. When attached, it can suck 5 to 15 mL of blood, an amount that is six to 10 times its body weight (Joslin et al., 2017). Duration of feedings vary anywhere between 20 and 90 minutes. When the leech is full, it will detach itself off of the tissue. Leeches should never be pulled off while actively feeding, as harm could occur. The could cause the leech to regurgitate its stomach contents into the open tissue. Leech rejection (when the leech does not attach, sucks slowly, or searches for other tissue) is an ominous sign. This usually signifies that the tissue is dying.

The frequency and number of leeches used in a session varies great ly. There is no consensus on this, and the size of the treatment area and the degree of congestion make it even more challenging to determine (Sig, 2017; Hackenberger & Janis, 2019). Studies have reported the use of one to five leeches per treatment. Frequency of sessions range from hourly to daily. When leech ther apy is used for venous congestion, it usually takes about 3 to 7 days until new vessel growth around the flap develops for effective venous drainage. Clinical response of the treatment tissue should be closely monitored with therapy modified as needed.

Leech saliva contains a number of biologically active substances that enter the host tissue during feedings. The most well-known natural an tithrombin is hirudin which inhibits the conversion of fibrinogen to fibrin, preventing blood from clotting. Leech saliva also has other substanc es that have properties of anticoagu lation, anti-inflammation, histamine vasodilation, anti-microbial action, and anesthetic and analgesic com pounds (Hackenberger & Janis, 2019). Hirudin works in conjunction with the vasodilators to relax the smooth muscle of the blood vessels, to widen the diameter of the vessel, and to increase blood flow to the area. The anesthetic and analgesic substances in the leech saliva allow for painless attachment and feeding.

Thus, the therapeutic effects of leech therapy are from these three main processes:

• Active removal of blood dur ing feeding

• Secretion of various bioactive substances (e.g., hirudin)

• Continual oozing of blood from the bite wound

• Obtaining and Maintaining the Leeches

As an FDA approved device, healthcare facilities using leech therapy can order leeches from many companies that sell them in the U.S. Facilities that do not have estab lished leech guidelines or protocols can follow the recommendations of these leech farms for application and use of the leeches.

Care for the leeches according to the instructions provided by the supplier. This usually involves placing them in a clean glass or plastic con tainer with sufficient fresh water. Use water that is nonchlorinated or dis tilled water with hirudosalt (Leeches U.S.A., n.d.). Do not use chlorinated tap water. The supplier may recom mend using a commercially available

additive specific for leeches to be added to the water.

When using leeches in heated rooms, ensure leeches are kept in a cool, dark place or the refrigerator. Avoid placing the leeches in direct sunlight. The temperature should aim to be around 40 degrees F and under 50 degrees F (Leeches U.S.A, n.d.). Avoid rapid temperature changes when moving leeches from the con tainer.

Store the leeches in a container with a perforated lid or a gauze pad or cloth. To prevent the leeches from escaping, make sure the cover is tightly secured with a string or rubber band. The leeches should not be overcrowd ed in the container. It is recommended that no more than 50 leeches be kept in a 10 liter container together (Leech es U.S.A., n.d.).

Before initiating therapy, the clinician should confirm the patient’s treatment area is not due to arterial in sufficiency and is indeed a venous con gestion issue (cyanotic color, cool to touch, brisk capillary refill). The nurse or other healthcare professional should also assess for pertinent medical his tory including the use of medications, vitamins, or herbal supplements. An ti-inflammatory medications or herbal supplements such as ginseng or ginkgo biloba may increase the risk of bleed ing. Other medications may reduce immune response and thereby increase infection risk (Spears, 2016). Because caffeine and nicotine from smoking are vasoconstrictive, they should be avoided while receiving leech therapy (Thakur et al., 2016).

Before applying leeches, wash the area with soap and water and rinse with distilled non-chlorinated (sterile) water. Leech therapy may be used in combination with heparin scrubs to prevent clotting and promote free bleeding. Heparin 100 units/mL placed on 2x2 gauze can be rubbed on site (usually in nail beds in reattach

THE OR continuing education

ments). Any residual heparin should be wiped off as leeches do not grav itate towards it (Bennett-Marsden & Ng, 2014).

Applying the Leeches

Recommended Method for Ap plying Leeches (Spear, 2016; Leaches U.S.A., n.d.):

Wearing nonsterile gloves, take a long pair of non-toothed forceps in one hand and carefully lift the lid of the container. Be prepared to see some leeches clinging to the sides and even the lid of the container. It will be easier at first to try to catch the leeches that are swimming. Remem ber, the ones on the sides adhere with the suction cup on their tail and are more difficult to detach. Try to quickly but gently grasp a leech and remove it from the container. Don’t be surprised if the side crawlers poke their heads out of the top. Just be careful that they don’t escape or get caught when you snap the lid back on. It is helpful to have someone help you at first until you get acquainted with how best to handle the leeches. It can be tricky enough grabbing a leech and getting it to the treatment area without having to worry about keeping the others in the container. Leeches are elastic and slippery, and this combination makes them difficult to carry. Avoid being forceful with the forceps to prevent damage to the leech. Picking up the leech using a gauze pad is also an option.

There are various methods when applying the leech to the skin:

• Syringe method

Remove the plunger from a 5 ml syringe and place the leech in the empty barrel of the syringe. Place the open end of the barrel on the treat ment site, where you want the leech to attach. Once feeding is established, gently remove the syringe.

• Gauze method

Dampen gauze with sterile water. Cut a 1 cm opening in a gauze pad

IN THE OR continuing education

and tape it to patient’s skin with the opening over the attachment site. This helps prevent the leech from migrat ing away from the site.

• Plastic cup method

A cup could also be used over the attachment site with the bottom cut out. This method also prevents leech from migrating away from the site.

Guide the leech’s head to the area to be treated. Hold the tail until the leech starts sucking, then release the leech. The leech usually does not take long to attach. However, if the leech seems unenthusiastic to bite, the clinician may pierce the skin with a small needle prick to produce a tiny droplet of blood, apply a drop of glucose, or try another leech. Con tinued resistance to feeding could be sign of poor arterial supply.

Suction cups are on the head and tail of the leech. The anterior head of the leech has a suction cup with three Y shaped jaws with teeth that are used to bite and attach to the treatment area. The tail end of the leech uses its sucker mostly for creeping and attaching. A rhythmic movement in the leech will be noted during feeding.

Once the leech is attached, allow it to stay in place until it is satiated and fully distended. The site should be checked about every 15 minutes to ensure that the leech hasn’t mi grated. Allow leeches to remain on the skin until they detach on their own. It is usually not much longer than an hour. Sometimes leeches attach but do not change or increase in size and have no visible gut peri stalsis within 30 minutes after their attachment. These leeches should be replaced with other leeches.

When leeches are finished feed ing, remove them with a gauze pad and place in a sealed container. Used leeches are euthanized with submer sion in a 70% alcohol solution. Dis pose per facility policy for disposal of biohazardous medical waste.

Document sites of leech attach ment, time of attachment, vital signs, vascular and skin assessment, esti mated bleeding from the site as well as patient’s teaching and tolerance of the procedure.

Medicinal leech suction action

Positioning: The area of surgical reconstruction should be elevated (upper extremity in a sling and lower extremity up on pillows). If arterial insufficiency is noted (pale, lack of bleeding, capillary refill time greater than 3 seconds), the extremity may need to be dangled in a dependent position for a short time to promote blood flow.

Monitoring: The site should be monitored for detachment of the leech to minimize risk of the leech’s migrating (Spear, 2016). Vital signs should be taken at least every 4 hours. Patients are at risk for in stability because of the blood loss from the leeches themselves as well as the resulting free bleeding. At a minimum, a complete blood count should be checked after 24 hours of continuous leech therapy. Patients receiving a course of treatment over multiple days may require blood transfusions. Assessment and docu mentation includes observation of the treatment site as well as patient’s tolerance of the procedure. Note the color and appearance of the tissue, the presence of pulses at or near the site, and an estimation of the amount of bleeding from the bites.

Never pull a leech off or squeeze a leech that is attached. It could cause parts of the leech to remain in the skin, increasing the risk for infec tion. As mentioned, infection is the most common complication of leech therapy. It is the consensus that patients undergoing leech therapy be treated with systemic antibiotics. Infections can occur within 24 hours or up to 26 days after the leech ther apy. Clinical signs of infection can

vary from a minor wound infection to extensive tissue loss (Herlin et al., 2017).

After Leech Therapy

Leeches are disposed of after a single use. They cannot be used on another person, and they cannot be used on the same person either. They must be destroyed by submerging the used leech in a container of 70% alcohol for at least 5 minutes. The dead leech is then disposed of with other biohazardous (blood and body fluids) waste or per facility policy (Spear, 2016).

One of the main therapeutic effects of MLT happens after the feeding period. Leech bites will continue to passively ooze blood for about 10 hours, but the time can range from a few hours to a few days (Pourrahimi et al., 2020; Joslin et al., 2017; Thakur et al., 2016). Because bleeding is encouraged at the bite site, any locally forming clot should be gently wiped away. However, prolonged bleeding leading to excess blood loss should be closely moni tored. Suturing bite sites or admin istering blood transfusions may be necessary (Wollina et al., 2016).

Emotional Support and Patient and Family Education

Patients and families are often ini tially repulsed by the idea of leech therapy. Nonetheless, when faced with the fear of flap failure or loss of a digit, they often grant consent for therapy. Patients’ and families’ acceptance of the therapy is a major part of its success. A family mem ber’s reaction to leeches can weigh significantly on the patient’s state of mind. Ask the patient and the family how they have dealt with “creatures” and “bugs” in the past. This infor mation will help you to determine how much emotional support will be required. As always, allow patients to express their fears and concerns about the treatment. Reassure them

this is an accepted medical treatment that has proved successful.

Allow the patient and their family to see a leech before therapy begins. Explain the mechanics of the procedure and how leech therapy works. Inform patients that leech saliva contains a local anesthetic and that the procedure is usually not painful. Allow them to read the literature sent with the leech shipment. Written material is often perceived as validation of a therapy and will provide the necessary re assurance that they are not the first to undergo leech therapy. When leech therapy is used in pediatric patients, it is often the parents, not the children, who express revul sion. Children often readily accept this treatment. It is essential that the parents’ fears and anxiety be allayed, because the child will per ceive these emotions negatively.

Leech therapy can be incorpo rated in the plan of care by using therapeutic play based on develop mental level. For example, the child can play and learn by mimicking the clinician’s interventions. A small piece of brown string and a pair of plastic tweezers can be used to replace the leech and forceps while the child applies the “leech” to healthy tissue. Diversion with games or books may also help if the child is anxious.

Before educating and providing emotional support to patients and their families, you as the health care professional may need to first deal with your own negative feel ings about leech therapy. An open discussion with the nursing staff on your unit may help in allaying stress and anxiety. Speaking to nurses and clinicians at other institutions who are more familiar with this treatment can also be helpful. The ordering physician may also be able to pro vide information and dispel myths about this therapy.

Crowd Control

Crowd control can become a real issue for the patient receiving this type of therapy. Leeches are fasci nating creatures, and they attract the curious from all over the hospital. During treatment, the clinician must weigh the potential for infection and the patient’s right to confidentiality against educating other health care workers. Obviously, personnel coming into direct contact with the patient will need to be educated to safeguard the procedure and prevent them from displaying emotional reactions to the leeches in front of the patient. For those who are simply curious, a brief explanation of the therapy and a quick peek at the leeches should suffice. Direct them to the leech container outside of the patient’s room or a visit to the phar macy to see the main container.

Leech therapy is an effective method of treating venous conges tion or pooling in tissue flap graft sites and reattached digits. While nursing care and management en compasses both the patient and the leeches, remember to keep things in perspective and maintain the patient as the primary focus of your care. Leech therapy is demanding and time consuming, and it can make you feel uncomfortable. However, it is rewarding to see a patient whose flap or digit has been saved using this unusual therapy.

Section 4: Conclusion Summary

Now that you have finished viewing the course content, you should have learned the following:

• Current clinical applications of leech therapy

• Appropriate nursing inter ventions for patients receiving leech therapy

• Ways to provide the education al and emotional support need ed by patients undergoing leech therapy and their families

Course Contributors

The content for this course was revised by Catherine R. Ratliff, PhD, GNP-BC, CWOCN, CFCN, FAAN.

Catherine R. Ratliff, PhD, GNP-BC, CWOCN, CFCN, an associate profes sor and nurse practitioner at the Uni versity of Virginia, is widely published in the fields of wound, ostomy, and continence care, and has spoken at national and international meetings.

This course was edited by Relias staff writer Sooa Devereaux, MSN, RN-BC.

Sooa Devereaux, MSN, RN-BC, has a long history of professional de velopment experience within the hospital setting. She has taught in pre-licensure nursing programs and has mentored many nurses, both new graduate and experienced, throughout her career as a nurse educator. Sooa holds an MSN in Nursing Education and certification in medical-surgical nursing.

Acknowledgment : Rebecca L. White, BA, RN, CCRN; Colleen M. Fries, BSN, RN, CCRN; and Maryann M. Wells, PhD, BSN, RN, FAAN, were the previous authors of this educational activity but did not participate in the revision of the current version of this course.

Resources

LEECH THERAPY: Step by Step Demonstration https://youtu.be/MS j5ZYbDSys

Mehdi Leech Therapy https://www. leechestherapy.com/about-leeches

continuing education

References

1. Aetna. (2020). Bio-surgery: medici nal leech therapy and medical mag gots. http://www.aetna.com/cpb/ medical/data/500_599/0556.html

2. Bennett-Marsden, M., & Ng, A. (2014). Hirudotherapy: a guide to using leeches to drain blood from tissue. Clinical Pharmacist. https:// www.pharmaceutical-journal.com/ publications/previous-issues/ cp-june-2014/hirudotherapy-aguide-to-using-leeches-to-drainblood-from-tissue/11136626. article?firstPass=false

3. Hackenberger, P. N., & Janis, J. E. (2019). A comprehensive review of medicinal leeches in plastic and reconstructive surgery. Plastic and Reconstructive Surgery — Global Open, 7(12), e2555. doi: 10.1097/ GOX.0000000000002555

4. Herlin, C., Bertheuil, N., Bekara, F., Boissiere, F., Sinna, R., & Cha put B. (2017). Leech therapy in flap salvage: systematic review and practical recommendations. Annales de Chirurgie Plastique Esthétique, 62(2), e1-e13. https://doi. org/10.1016/j.anplas.2016.06.004

5. Hohmann, C. D., Stange, R., Steck han, N., Robens, S., Ostermann, T., Paetow, A., & Michalsen, A. (2018). The effectiveness of leech therapy in chronic low back pain. Deutsches

Clinical Vignette Taylor’s Story

Taylor is a 25-year-old patient who suffered a severe crush and avulsion injury to his right forefinger. This injury occurred at his workplace when his finger got caught in the gears of the machinery which resulted in contusions, lacerations, and the complete detachment of his finger. He was immediately transferred by ambulance to the hospital. He was

Arzteblatt International, 115(47), 785–792. https://doi.org/10.3238/ arztebl.2018.0785

6. Iskik, M., Ugur, M., Yakisan, R.S., Sari, T., & Yilmaz, N. (2017). Comparison of the effectiveness of medicinal leech and TENS therapy in the treatment of primary osteoarthritis of the Knee: a randomized con trolled trial. Zeitschrift für Rheuma tologie, 76(9), 798-805. https://doi. org/10.1007/s00393-016-0176-1

7. Joslin, J., Biondich, A., Walker, K., & Zanghi, N. (2017). A comprehen sive review of hirundiniasis: From historic uses of leeches to modern treatments of their bites. Wilder ness & Environmental Medicine, 28, 355-361.

8. Kalender, M.E., Comez, G., Sevinc, A., Dirier, A., & Camci, C. (2010). Leech therapy for symptomatic relief of cancer pain. Pain Medi cine, 11(3), 443-445. https://doi. org/10.1111/j.1526-4637.2010.00800.x

9. Koeppen, D., Aurich, M., & Rampp, T. (2014). Medicinal leech therapy in pain syndromes: a narrative review. Wiener Medzinische Wochen schrift, 164(5-6),95-102. doi: 10.1007/ s10354-013-0236-y

10. Leeches U.S.A. Maintaining leeches. http://www.leechesusa.com/infor mation/maintaining-leeches

11. Pourrahimi, M., Abdi, M., & Ghods,

considered a trauma case and brought directly to the OR for microvascular surgery. Taylor underwent 12 hours of surgery for surgical reattachment of his finger. Postoperatively, he was admitted to the surgical ICU. Six hours later, venous congestion was noted. Medical leeches were ordered to save the patient’s finger. Four leeches were applied and replaced with new leeches each time the engorged leeches detached. The patient experienced no pain while leeches remained on the

R. (2020). Complications of leech therapy. Avicenna Journal of Phyto medicine, 10(3), 222–234.

12. Sig, A. K., Guney, M., Uskudar Guclu, A., & Ozmen, E. (2017). Medicinal leech therapy-an overall perspec tive. Integrative Medicine Re search, 6(4), 337–343. https://doi. org/10.1016/j.imr.2017.08.001

13. Spear, M. (2016). Medicinal leech therapy: friend or foe. Plastic Surgical Nursing, 36(3), 121-125. https://doi.org/10.1097/ PSN.0000000000000152

14. Thakur, I., Satheesha Reddy, B. H., Patil, S., & Rajendra, K. (2016). Hiru dotherapy in dentistry. International Journal of Oral Health Sciences, 6(2), 65-69. doi: 0.4103/22316027.199987

15. Whitaker, I.S., Oboumarzouk, O., Rozen, W.M., Naderi, N., Balasubra manian, S.P., Azzopardi, E.A., & Kon, M. (2012). The efficacy of medicinal leeches in plastic and reconstruc tive surgery: a systematic review of 277 reported clinical cases. Micro surgery, 32(3), 240-250. https://doi. org/10.1002/micr.20971

16. Wollina U., Heinig B., & Nowak A. (2016). Medical leech therapy (hirudotherapy). Our Dermatol ogy Online, 7(1), 91-96. doi: 10.7241/ ourd.20161.24

wound site. While undergoing leech therapy, the patient was assessed for potential blood loss. If the wound showed signs of infection, debridement would not be a viable treatment. After 48 hours, a definite improvement in venous congestion was noted. After 70 hours, the finger was less swollen and greatly improved, and venous drain age was visible. After 5 days postop eratively, venous flow was sufficiently restored.

Clinical VignettE ANSWERS

Infectionisthemostcommoncomplicationofleechtherapy.Itis theconsensusthatpatientsundergoingleechtherapybetreated withsystemicantibiotics.

Surgeonsdonotdebridetheareafearingtheymaylosethe finger.Theleech’sgutharborsbacteriaknownasAeromonas hydrophila,agram-negativerod,helpsinthedigestionofin gestedbloodandproducesanantibioticthatkillsotherbacteria.

Answer:D,Theanestheticandanalgesicsubstancesintheleech salivaallowforpainlessattachmentandfeeding.4.Answer:D,

1.Answer:A,Leechesconsumesurplusbloodandmaintainflow throughthevesselbyuseoftheirownanticoagulantproduced intheirsecretions.2.Answer:B,Thetissuebeingtreatedshould beobservedforbleeding.Ifbleedingispresent,thenthepa tient’shemoglobinlevelsshouldbechecked.Itispossiblefor significantfallsinhemoglobinlevelstooccuratthistime.3.

How to Earn Continuing Education Credit

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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

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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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BUILD

BY DON SADLER

BETTER

Many hospitals and ambulatory surgery centers (ASCs) today look more like construction zones than health care facili ties as they build new perioperative suites and renovate existing suites to keep up with patient demand and new technol ogy requirements.

“Renovating and building periopera tive suites has become one of the fastest growing skill sets for health care leaders,” says Aimee Watson, MS, CMRP, a senior manager in healthcare at St. Onge, an in dependent engineering firm that provides design, logistics and supply chain consult ing to hospitals and ASCs. “But we never received a class on this in school.”

Aging Buildings and More Watson says that OR suite construction and renovation is on the rise nationwide for several different reasons. “These include aging buildings, changes in reim bursement models, demands for specialty OR suites, outdated equipment, and the need to bring existing suites up to new codes and standards,” she says. “New and renovated suites can also help attract a more talented surgical team.”

Erin Kyle, DNP, RN, CNOR, NEA-BC, editor in chief, Guidelines for Perioperative Practice for the Associa tion of periOperative Registered Nurses (AORN), concurs.

“Aging buildings and advancements in technology are two of the main reasons hospitals are building out new periopera tive spaces,” she says. “Some hospitals

need updates to support changes in the way care is delivered in procedural areas.”

Beverly Kirchner, BSN, RN, CNOR, CNAMB, also stresses the role of tech nology in the current wave of OR suite construction and renovation.

“For example, robots may require a larger room to be safe using advanced technologic equipment,” says Kirchner. “And ASCs are developing new service lines now that CMS has allowed them to perform more complicated cases. These include total joints, interventional vas cular and cardiology, and more complex spine cases.”

Patients are also helping drive the need for more ORs.

“Most patients are unwilling to wait for elective, urgent or emergent surgery,” says Kirchner.

Kyle uses one word to explain the boom in OR suite renovation and con struction. “Growth!” she says.

“Hospitals expand along with the communities they serve and their services grow to meet the community’s needs,” says Kyle. “This might be due to population growth or changes in the community’s health needs. For example, an aging population might lead to a need for more services for age-related health concerns.”

Competition is another factor. “Every hospital wants to emphasize in their marketing what their competitors do not have to help attract new patients and in

crease market share,” says Kirchner. “ASCs also do some of this kind of marketing, but not as much as hospitals.”

“Every Project is Different” Kirchner has helped design and build more than 30 surgery centers through out her career. “Every project is differ ent,” she says. “We build our ORs to meet the needs of the specialties that will provide services.”

“For example, ortho, spine and robot rooms are not less than 600 square feet, and I prefer 750 square feet if possible,” says Kirchner. “Also remember that under federal regulations, the number of operating rooms in an ASC drives the number of preoperative and PACU bays or rooms.”

One of Kirchner’s most important success factors is being sure to work with an experienced architect who under stands the complex federal and state regulations that govern the construction and renovation of OR suites.

“The architect must have a great engineering team to design the structural needs of the room,” says Kirchner. “This includes HVAC, integration of equip ment through technology, and electrical requirements to accommodate the elec trical loads that run to the equipment.”

“Hospitals expand along with the communities they serve and their services grow to meet the community’s needs.”

–Erin KYLE

Considering patient flow is also critical when building and renovating perioperative suites.

“You do not want to cross the fresh post-op with a patient in preop, and you want maximum privacy from the space you have been allotted,” says Kirchner. “Your ORs also must be central to where the dirty instruments go for reprocessing and the sterile instruments and supplies are stored.”

Erin Keeney, MSN, RN, CNOR, the director of perioperative services at AnMed,

has overseen a major OR construc tion and renovation project over the past few years at AnMed in Anderson, South Carolina. This has included building two new operating rooms to support growing orthopedic volume and renovating two existing ORs to create four new endoscopy/bronchos copy suites.

“In addition to orthopedics, the new ORs can be used by all surgical services if needed,” says Keeney. “We also built a new same-day surgery and a new post anesthesia care unit as well as new of fices, staff and physician lounges, locker rooms and storage, and a new family waiting area.”

Keeney says the project has been much larger than what was

originally envisioned and won’t be complete until March 2023.

Early on, Keeney and her team held monthly meetings with the architects, design and construction team, infec tion prevention and engineering. “Those meetings became weekly once we got into the construction phases,” she says.

“We brought in physicians and key OR personnel to get input on the designs,” says Keeney. “And I met with sales reps to make sure that the standard ization of what we currently had in the ORs would match the new areas.”

Working Around Obstacles

When it comes to unexpected surprises or obstacles, Keeney says there are always things that go differently than planned. “When this happens, we regroup to go over the concerns and issues and develop a new plan to make sure we stay on track,” says Keeney. “Keeping an OR run ning while under construction definitely has some challenges, which makes being open and flexible to change extremely important.”

Keeney’s main advice? “Be patient and willing to think outside the box,” she says. “Prepare yourself and your team for change and engage the physicians and staff. And communicate regularly with the construction team and infection prevention to make sure that your other operating rooms are protected.”

“I also think it’s important to engage staff and physicians and ask them about any barriers in the current ORs,” Keeney adds. “Find out what their ‘wish list’ would be for the perfect OR and incorporate as much of this as you can into the design.”

According to Kyle, the foundation of a successful perioperative suite build is a solid understanding of the patients and population that the space will serve.

“Getting your arms around the patient population, anticipated services and the technology needed to offer the best care is no easy task,” says Kyle. “This is where the interdisciplinary team must come together to clearly define the strategic goals related to designing the anticipated build.”

Having the right people at the right time with the right authority is the stron gest indicator of health care design suc cess, Kyle adds. “Convening an interdisci plinary team with internal stakeholders can provide necessary insight into the best feasible practice design,” she says.

Remember the Five E’s Mary Alice Anderson, Ph.D., RN, CNOR, senior perioperative practice specialist with AORN, stresses what she calls the five E’s when it comes to designing, building and renovating peri operative suites.

“First, every detail matters in the long-term strategic plan,” says Anderson. “The next E is efficiency: Designing the space to support efficient workflows should be a top priority.”

Ergonomics is also critical. “The space should be designed in a way that helps perioperative teams perform their best and be protected,” says Anderson.

The fourth E is emerging technolo gies. “Do what you can to anticipate how the perioperative environment will sup port what kinds of technology are next,” says Anderson.

Finally, you need to make sure that the perioperative suite’s electrical capac ity can support all the equipment that will be running simultaneously.

“Also consider electrical and network ing interference issues,” says Anderson.

According to Watson, building a cross-functional team is critical to the success of the design and operation of new periop erative spaces.

“This team should include representa tion from pre-op, PACU, sterile process ing, anesthesia, support services and administration, cath lab, CV holding, and even infection prevention and environ mental services,” she says.

“The goal of having a group like this come together is to establish the team’s goals, define roles, build trust and foster open communication,” says Watson. “Eventually perioperative team members should be able to simulate and practice within their new spaces before opening the new ORs.”

In her experience, Watson has seen a number of “oops” when it comes to OR suite design. These include kick plates in stalled too high to open doors, fire doors installed backward, access panels installed where carts will sit, a hand sanitizer dispenser installed behind the patient bed and an OR floor that did not meet infection prevention standards.

“These mistakes could have been avoided if the perioperative team had a voice and a seat at the table during the design and construction process,” says Watson.

Design and Construction Challenges

Supriya Patel, engagement manager with Surgical Directions, lists some of the biggest challenges when it comes to designing and building new periopera tive suites.

“Appropriate block allocation, proper EMR integration, effective patient preparation and pre-admission testing processes, and standardization of ancil lary department workflows are among the biggest challenges I see,” she says.

“These challenges make it critical to get staff and clinician input when designing new perioperative suites,” says Patel. “They understand the workflows

and operational day-to-day challenges that occur.”

Block allocation is usually one of the most pressing concerns for OR leader ship and physicians. “I recommend orga nizing a block subcommittee comprised of both physicians and OR leadership to review current blocks, forecasted data and best practice guidelines,” says Patel.

Pre-admission testing and patient preparation are other areas where Patel has direct experience in OR suite design. “These play a crucial role in operational efficiency,” she says. “The patient prep system should be redesigned with the correct players well in advance of the new build. Ideally, patients should be prepared for surgery at least three days prior to the procedure.”

Some of the biggest mistakes Patel sees hospitals make when designing and building new perioperative suites involve communication and planning.

“Making sure staff and clinicians are involved in the design will go a long way toward the success of the new suite,” she says. “This is important not just for op erational success, but also from a patient safety standpoint.”

Kirchner stresses the importance of looking ahead to what a surgical center will need to grow in the future. “For example, I always plan on an additional autoclave and washer decontaminator,” she says. “I have the plumbing put in and capped so it is almost plug-and-play when I need that autoclave or washer disinfector.

“The decision to design for the future is determined by strategically forecasting case growth from opening to five years out,” says Kirchner. “This process saves a lot of time, decreases disruptions and helps in constructing an infection preven tion plan when new ORs are added.”

Kirchner also recommends creating a construction checklist identifying key phases. “Ask the architect and contrac tor for timelines,” she says. “Know the regulations that address and govern your project and make sure they are met.”

The Role of Hybrid Suites

Watson says that every hospital St. Onge works with is planning for flexible, or hybrid, OR suites. “This provides the op portunity to perform a variety of cases within that one suite – from OR to cath lab or specialty procedures,” she says.

Watson’s success tips for building and renovating new OR suites include making sure growth projections are ac curate so as not to undersize the space and planning appropriately for which supplies and equipment will need to be in the room.

“Perioperative team members should grab a seat at the table wherever they can in the process,” says Watson “At the beginning during concept design is best. Identify someone as a dedicated liaison for the teams to work on the new project.”

It’s common for hospitals to partner with outside consultants who have op erational experience and the industrial engineering skills to help with flow and design needs. “It can be difficult to juggle your day-to-day responsibilities while also trying to oversee a major new OR suite construction,” she says.

Anderson stresses that it’s criti cal to keep patient needs top of mind when designing new OR suites. “This means thinking about how the patient will experience the space and how the space supports the perioperative team in delivering optimal care,” she says.

“The decision to design for the future is determined by strategically forecasting case growth from opening to five years out. This process saves a lot of time, decreases disruptions and helps in constructing an infection prevention plan when new ORs are added.” –Beverly Kirchner

By Matt Skoufalos

As early as middle school, Katie Chargualaf found herself contemplating a career in health care. Growing up in a family of health care providers, where health care was commonly talked around the dinner table and at holidays, made it easy for her to see herself entering the field. Chargualaf was hesitant, however, because she felt an equally strong pull to consider a career in education. While volunteering in a hospital one evening, she had an epiphany that maybe she didn’t have to choose between the two.

“I love both and I could see myself doing both,” Chargualaf said. “One night, it finally hit me that teachers couldn’t nurse, but nurses could teach. If I go into nursing first, and I want to pursue teach ing, I could teach nursing.”

With the added benefit that her mother, Kathryn Barnes, could help guide her through nursing school, Chargualaf graduated from the same nursing pro gram her mother had 30 years earlier: the Bon Secours Memorial School of Nursing (now Bon Secours College of Nursing) in Richmond, Virginia.

“I’m grateful for her guidance,” Char gualaf said. “It fostered in me a love of doing more.”

As much as Chargualaf’s career

path was guided by the influence of her family, it was equally affected by her husband’s 21-year career in the U.S. Air Force, during which the family moved 14 times across America, with one stop in South Korea. Those assignments af forded her the opportunity to prac tice nursing in different geographical regions, in areas both rural and urban, and offered a rich opportunity to see how the same types of patients are cared for differently.

“That was very valuable to my practice, and something that I bring into the classroom today,” Chargualaf said. “I found these variations, and it just contin ued to fuel my love of learning.

I can teach you one way to care for

Katie Chargualaf, Ph.D., RN, CMSRN Associate Professor of Nursing, University of South Carolina Aiken

Katie Chargualaf, Ph.D., RN, CMSRN

Associate Professor of Nursing, University of South Carolina Aiken

SPOTLIGHT ON:

a patient, but that’s not the only right way to do it.”

The family’s first stop was in San Antonio, Texas, where Chargualaf took a position in a 40-bed medical/surgical on cology unit. There she cared for patients who didn’t require intensive monitoring or highly complex medications, as well as oncology patients, so she became certi fied to administer chemotherapy.

“What I learned about being a postsurgical nurse there stuck with me for the rest of my career,” Chargualaf said. “It was such a great learning environment. I found myself hanging by the bedside because is was a great lesson for me. That first job created such a solid foundation for my practice for two decades; there are still patients I remember, and I still keep in touch with the nurses I worked with back then.”

From San Antonio, Chargualaf headed to a long-term care and acute re habilitation facility in Rapid City, South Dakota, for her first time practicing nursing in a rural setting. She recalls the assignment as being her first time practic ing outside of her comfort zone.

“That was a steep learning curve,” Chargualaf said. “You had to be resource ful there. You didn’t have everything at your fingertips. You had to think for your self, be innovative and suggest some ideas. I looked at patient outcomes through a new lens. From that point forward, I didn’t go into it as ‘my job is to follow the doctor’s orders, do everything they say and go home at the end of the day.’ I can play a more active role in patient care on my unit, and how we do things as a unit.”

That assignment also instilled in Char gualaf a desire to advance her education and earn a master’s degree. The notion that additional schooling could help her deliver better patient care and expand her practice opened Chargualaf’s eyes to the notion of becoming a lifelong learner, the better to expand her skill set with each new setting in which she worked.

“It sparked this return to school that has continued to follow me,” Chargualaf said. “I just keep going back. I love learning. Health care keeps changing, and nurs ing practice has to follow suit to those changes. I need to make sure that I’m do ing right by my patients. I need to make sure I’m giving the best, most evidencebased information that I can to make sure the next generation is ready for the challenge.”

Chargualaf graduated from the University of Phoenix in 2008 with a master’s of science in nursing, and a concentration in nursing education. She recalled helping her young children with schoolwork during the day, and then clearing the space for her own course work at night.

“I put a little red table in my office, and gave my kids their homework while mommy did homework,” Chargualaf said. “We were all in school together in the evenings. My youngest was practicing coloring in the lines, while my oldest was practicing his letters. They were learning while I was learning, and I think it made

a lasting impression.”

Chargualaf accepted her first teach ing position at Marymount University in Arlington, Virginia, and quickly fell in love with it. While teaching nurs ing fundamentals and medical-surgical nursing, she learned how suited she was for a career in nursing education. By 2015, she’d completed her Ph.D. at the University of Hawaii, and by 2018, the family had settled for good in Augusta, Georgia, where she is currently an associ ate professor of nursing at the University of South Carolina in Aiken.

“I love that the health care communi ty in our area is just the right size, where you know people at different facilities, and can network and make those connec tions,” Chargualaf said. “I’m teaching in the classroom, and being here is support ive of my research. It’s everything that I could have imagined wanting in my forever-job home. I feel like it’s where I was meant to be.”

“It’s everything that I could have imagined wanting in my forever-job home. I feel like it’s where I was meant to be.”

- Katie Chargualaf

Risk of premature death in adulthood influenced by patterns of early childhood adversity

Poverty, combined with other types of adversity in early childhood, is associated with greater chances of premature death in adulthood, compared to other adverse childhood experiences, according to a study of more than 46,000 people by researchers at the National Institutes of Health.

Compared to children who did not experience early life adversity, childhood poverty combined with crowded hous ing was associated with a 41% higher risk for premature death, and early poverty combined with separation from a parent was associated with a 50% increase in premature death. Those who experienced parental harshness and neglect had a 16% higher risk of premature death, and those who experienced family instability had a 28% higher risk for premature death.

The findings build upon earlier studies that linked individual types of adverse childhood experiences to risk of death, as well as other studies that demonstrated that death risk rose as exposure to childhood adversity increased. The current study identifies links between combinations of early childhood adversity and the overall chances of premature death.

“Understanding how patterns of early childhood adversity are associated with shortened life expectancy helps us better understand the toll of early experiences on human health

and the extent that this toll carries over from childhood through adulthood,” said the study’s senior author, Stephen E. Gilman, Sc.D., chief of the Social and Behavioral Sciences Branch at NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). “In the long run, we hope that results such as ours can inform efforts to develop better interventions that would both re duce exposure to childhood adversity and reduce the health consequences of early adversity among exposed children.”

The study, conducted by investigators Jing Yu, Ph.D., Gilman and other NICHD colleagues, appears in The Lancet Regional Health-Americas.

The study participants were offspring of mothers who enrolled in the Collaborative Perinatal Project, a study on maternal and child health conducted by NIH. The research ers compared data from death records compiled from 1979 to 2016 to data that assessed the children’s experiences from when they were born, from 1959 to 1966, through age 7. Among the 46,129 study participants in the analysis, 3,344 deaths occurred. Based on questionnaire information and other data collected from the participants’ mothers, the researchers developed five classifications of early childhood adversity:

• Low adversity: unlikely to have experienced any significant childhood adverse events (48% of partici pants)

• Parental harshness and neglect: likely to have expe

OUT OF THE OR health

rienced such adverse events as parental physical or emotional harshness and physical neglect (4% of participants)

• Family instability: likely to have experienced two or more chang es in their parents’ marital status, parental divorce or separation, frequent changes in residence, a parent’s or sibling’s death, or foster care (9% of participants)

• Poverty and crowded hous ing: likely to have experienced poverty and crowded housing conditions (21% of participants)

• Poverty and parental separa tion: likely to have experienced poverty, welfare receipt, parental divorce or separation, and mari tal and residential changes (19% of participants)

In addition to the higher death risk of those in the latter four classes, pre mature death risk increased with the number of adverse childhood experi ences. Individuals with two adverse ex periences had a 27% higher risk of early death; three adverse experiences, a 29% higher death risk; and four adverse experiences, a 45% higher risk.

“Our findings and those of previous studies on childhood adverse experi ences highlight the need to reduce children’s exposure to the types of adversities that many face today, including poverty, poor housing condi tions and parental separation,” said Yu. “These experiences can affect brain development, social and emotional well-being, behavioral development and, as our results suggest, can reduce life expectancy.

References

Yu J.,

Single Leg exercises to double your strength

By Miguel J. Ortiz

When it comes to overall strength, most of the bigger lifts like deadlifts, squats and cleans are heavy compound movements. It is a process to master them. On a different spectrum, when recovering from an injury you’ll have to deal with imbalances during physical therapy.

The point is that at one point or an other you’ll need to be doing unilat eral or single-leg exercises to continue moving forward. Unilateral or singleleg exercises are very underutilized and underappreciated. They are great for strengthening joint imbalances, adding core strength and improving stability which all assist in develop ing overall strength. So, here are three single-leg exercises that you can start doing at home or in the gym.

The first exercise is the kettlebell goblet Cossack squat. This movement requires you to start in a wide stance and then shift into a single leg squat or lateral lunge. It covers the quads, adductors, glutes and core. This forces your weight to one side. Don’t be fooled. Sometimes getting down is easier than getting up, so be mindful of your range of motion and flexibility.

The opposite (or straight leg) will also go through an inner thigh stretch. So, keep in mind that while one hip is being stretched the other is being en gaged. This is forcing your core to sta bilize accordingly. Which brings me to the front-loaded kettlebell or weight. Adding weight will help stabilize your balance and you may find it slightly easier to get lower ranges of motion.

The second exercise requires a little more balance. The assisted oneleg Romanian deadlift (RDL) with bench. This movement can also be done with a dumbbell. It can also be done without a bench. However, if you have not done it before I recom mend using a bench because it will help with correct form before adding weight. This is a very easy exercise to manipulate improperly which can lead to compensation or bad form. The posterior system needs to be trained much more than what most see in gyms and it is vital for movement. This would include the calves, hamstrings, glutes, all of the back (core), shoul ders, triceps and neck. All of these areas are crucial for posture, walking, sitting and basically all movement. Notice the alignment from my heel, knee, hip, back, shoulders and neck in my video (tinyurl.com/ORTfitness). Everything is aligned, and by focusing

on this alignment you will target all these areas, including the hamstrings and glutes more than others. The RDL tremendously improves stability, hip and core strength.

Lastly, to combine the two move ments above, I give you the Bulgarian split squat. It is also known as the dumbbell rear leg elevated split squat, RLESS for short. This movement is not your normal split squat because the back leg is elevated forcing you to add significantly more weight to your front leg. This is an exercise that is going to burn quite a bit. The back leg gives reassurance, but is only assisting with stabilization. This movement can really expose hip imbalances so form is very important. Perfect your form first and then add weight as you feel more comfortable.

Enjoy your movements and 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 profes sional experience. He can be found on Instagram at @migueljortiz. You can find videos of the exercises men tioned in this column on his YouTube channel at tinyurl.com/ORTfitness.

OUT OF THE OR EQ Factor

Two Steps for Creating Understanding

By Daniel Bobinski

O ne of the most practical conflict resolution tools available is found in Stephen Covey’s best-selling book, “7 Habits of Highly Effective People.” That tool is Habit 5: Seek First to Understand, Then be Understood.

As described previously in this space, Habit 5 is the manifestation that fol lows the mindset described in Habit 4: Think Win-Win. The nice thing about Habit 5 is we are given a specific order of events to follow.

• Seek to understand the other person’s perspective

• Seek to communicate our perspective

The order is important, because as the old adage goes, people don’t care how much you know until they know how much you care. Covey’s fifth habit is valuable here, because you will demonstrate you care if you seek to understand other people’s perspectives before trying to commu nicate your own.

Going through the motions just won’t do. It’s important that we truly seek to understand the other person’s perspective. If we don’t have a genuine desire to understand another’s point of view and we mechanically go through the motions, the sincerity of our char acter can be called into question. When that happens, trust can waiver, making forward progress more difficult.

Said another way, it doesn’t matter

if we think we understand someone else. If the other person doesn’t believe it, it won’t matter what we think. For this method to work, it is incumbent upon us to clearly demonstrate the fact that we’re truly listening.

Also, if we don’t genuinely under stand, there’s a good chance any solu tion we suggest for solving a problem won’t truly fix the problem. Covey’s phrase to prevent this from happening comes in the form of a simple phrase: diagnose before you prescribe.

Diagnose before you prescribe Allow me to ask – have you ever been to a doctor or other profes sional who simply went through the motions of acting like listening was occurring, but you could tell that wasn’t the case?

Imagine going to a doctor because you have pain in your abdomen. Your doctor nods her head a few times as you describe your symptoms, then says you have a bad case of gas and prescribes some antacids. If her lack of genuine listening results in a wrong diagnosis, you could end up with a ruptured appendix.

By the same token, your doctor may nod her head a few times and then proclaim your pain is caused by appen dicitis. Before you know it, you’re being wheeled into the operating room for an appendectomy. What a horrible situation that would be if the true cause of your pain was only a bad case of gas!

Covey emphasizes the need to diagnose before we prescribe. Every situation is different. Even if a problem we’re hearing about is 90 percent like 100 problems we’ve solved before, there’s still a 10 percent differential, and if we’re not truly listening, that 10 percent difference could change everything about the best way to move forward.

In the field of emotional intelli gence, this skill of genuinely listening and genuinely caring about what some one is trying to communicate is called empathy. It comes easier to some than to others, but I’m a firm believer that if people set their mind to practice it, it’s a skill that can be learned.

Daniel Bobinski, who has a doctorate in theology, is a bestselling author and a popular speaker at conferences and re treats. For more than 30 years he’s been working with teams and individuals (1:1 coaching) to help them achieve excellence. He was also teaching Emotional Intelligence since before it was a thing. Reach him by email at DanielBobinski@ protonmail.com or 208-375-7606.

OUT

nutrition

Redefining Convenience in the Kitchen

By Kirsten Serrano

Life throws a lot at us.

Folks like you working in health care have had to adapt on the fly. You have likely found wells of flexibility you didn’t know you have.

When we are overwhelmed, it is only natural to look for ways to make things easier. Life in America presents plenty of opportunities to make food uber convenient. The drive through beckons. The microwaveable meal calls our name. We rely on carry-out. I am all for conve nience, but too much of it does not do a body good.

It is possible to eat for health and not spend all your time shopping, cooking and cleaning. I think of this as redefining convenience. It’s an informed nimbleness to make a better choice. Food can embrace conve nience and health if you tweak your definition of convenience a bit.

There are two things at play when we take a real look at the lure of con venience. One is the time involved. We all lead hectic lives. The other is the comforting embrace of having someone else do the labor. That is the reason we love to go out to a full-service restaurant. It is also the reason that when there is a crisis, the comforting response is often an arrival of casseroles to your doorstep. Let’s take a look at ways to trim back the time prepping food and ways to up the comfort level of food.

Redefining convenience and saving time: Prepare, prepare, prepare.

• Make a plan. It can just be 3-4 dinners a week to start.

• Order groceries online for pickup or delivery. Huge time saver.

• Prep produce in advance or even outsource the prep.

• As you prep produce, keep in mind that the smaller something is, the faster it will cook. It takes

a while to roast a brussel sprout, but it takes just a few minutes to sauté shaved ones. Tools like a food processor and a spiralizer really save time.

• When you cook, make extra. This one simple change will mean dinner is already done on days when you just cannot do one more thing.

Stock your kitchen.

• Buy high-quality marinades, salsas, seasoning packets, sauces and condiments that allow you to quickly prepare a meal that has great flavor.

• Instant, whole food sides:

* Raw veggies like tomato, cucumber, celery, carrots

* Fresh fruit

• Stock your pantry with items like canned tuna/salmon, applesauce, canned beans, pasta, rice, etc. All of these are items that make quick meals.

OUT OF THE OR nutrition

• Keep some frozen veggies around. Fresh is fantastic, but frozen vegetables are great too and more nutritious than canned ones.

• Keep boiled potatoes and boiled eggs in your fridge. A boiled potato can quickly become a cold or warm salad, hash, or part of a soup or curry. Boiled eggs are a great convenient snack on their own or they can be turned into egg salad or deviled eggs in a jiffy. Combine the eggs and potatoes into traditional potato salad.

Reduce clean up time

• One pot meals like pasta, a sheet pan dinner or a quick skillet meal make clean up easier.

• If you really want to cut down on dishes, use paper plates. It is not the most sustainable choice, but it is a lot better than the packaging that comes with takeout.

• Outsource the clean up. If you cannot do that within your household, maybe you can hire someone to pick up the slack. What you save on takeout might be better spent on some help at home.

Embrace technology

• Gadgets do make a difference. A pressure cooker, air fryer, microwave, and rice cooker really do save time (and your sanity). They can also save on clean up time. I use my combination air fryer/broiler/toaster oven to make about 70% of our meals.

• Look for ways to program convenience. You can program a lot of gadgets to start and stop when you want. My oven allows me to program on and off times. There’s nothing more convenient and comforting than walking into your house and knowing dinner is ready.

When all else fails

• Try out one of the many meal kit delivery options.

• Buy a roast chicken, a salad kit, bread and some fruit. Dinner served.

See if you can find a local service making fully prepared but

still high-quality foods to supplement your cooking. Part of my restaurant’s business model includes running a subscription meal service with our own farm’s produce.

Redefining convenience and increasing comfort:

• Flavor is comforting! Lean into those bottled sauces, marinades and condiments. A chicken breast on its own is boring. A chicken breast topped with a chunky green salsa and a little Cotija cheese is enticing.

• Embrace your comfort foods by loving leftovers and previously prepared foods. Do you have a favorite chili recipe? Make more than you need and freeze some. It will warm you up after a long day. Love lasagna but know it takes too much time to make on a weeknight? Next time you make one, make two instead. Freeze the second (cooked or uncooked) for another day.

• Eat dessert! If knowing you can end your day with a piece of chocolate cake is what you need to motivate you to eat a home cooked meal, go for it.

If you find yourself leaning heavily on takeout, restaurant meals, fast food and the like and you think your health is paying the price, I encourage you to gradually shift to eating home-cooked meals more often. The best place to start is with some basic meal planning and making leftovers. You’ve got this.

Kirsten Serrano is a nutrition con sultant, 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.

A Homemade Crunchy Mushroom Wrap to Save Your Grocery Budget

By Family Features

I f the prices of your favorite ingredients have you dreading the next trip to the grocery store, finding ways to stretch your budget can help you feel better at the checkout counter.

One such way: turning to versatile ingredients that help make every dollar count by using them in a variety of your family’s favorite meals. Flavorful op tions like mushrooms enhance recipes by extend ing portions when you use a process called “The Blend.” Blending finely chopped mushrooms with

Blended Crunchy Mushroom Wraps

Recipe courtesy of the Mushroom Council

Prep time: 15 minutes

Cook time: 20 minutes

Servings: 6

1. In large skillet over medium-high heat, heat olive oil. Cook onions 1-2 minutes until translucent. Add mushrooms and ground beef. Cook about 5 minutes, or until beef is no longer pink. Stir in taco seasoning. Cook 2-3 minutes. Set aside.

2. Lay one large flour tortilla on flat surface. Spread 2 tablespoons mushroom-meat mixture on center of tortilla.

3. Drizzle dollop of nacho cheese over mushroom-meat mixture. Top meat with one tostada shell then spread thin layer of sour cream over tostada shell.

ground meat allows you to extend the volume of dishes like burgers, tacos, pasta, wraps and more. Simply chop your desired mushroom variety to match the consistency of ground meat, blend the chopped mushrooms and meat together then cook your blend to complete the recipe. This Blended Crunchy Mushroom Wrap is a perfect example of an easy yet delicious way to take your grocery budget further.

Visit MushroomCouncil.com for more blended recipe ideas.

4. Top with shredded lettuce, diced tomatoes and shredded Mexican cheese then one small tortilla. Make sure not to overstuff so wrap doesn’t break apart while cooking.

5. Fold edges of large tortilla toward center until completely covered.

6. In hot skillet, generously spray with nonstick cooking spray. Carefully place wrap seam side down on skillet. Cook 2-3 minutes until golden brown.

7. Flip and cook other side until golden brown. Repeat with remaining mushroom-meat mixture, tortillas and toppings.

8. Cut wraps in half and serve.

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The News and Photos that Caught Our Eye This Month

5 Ways Society Benefits When Kids Spend More Time with Dad

By FAMILY FEATURES

A

ccording to Pew Research Center, 63% of dads report that they feel they don’t get to spend enough time with their children. When it comes to dads in co-parenting situations, that number is likely even higher. What may come as a surprise to many is that society is also missing out on something when this happens. Children around the nation are greatly missing out on things when they don’t get enough time with their fathers.

“When fathers are actively involved in their lives our children are happier and safer, and our society is healthier and more productive,” said Dads’ Resource Center Founder and Chair Dr. Joel N. Myers. “But instead of celebrating fatherhood and looking for ways to ensure father involvement, our government pours hundreds of billions of taxpayer dollars a year into public assistance and social services.”

According to the U.S. Census Bureau, 121 million men in the country are biological fathers of at least one child under 18. This demonstrates that the impact that fathers have on the lives of these children is going to be far-reaching.

Several years ago, Fortune reported that men who spend more time with their kids make happier employees. Based on research, it was suggested that companies should give men more time to spend with their families to increase retention rates. Having happier men at work is one way society benefits when dad gets more time with the kids.

Here are 5 additional ways society benefits when kids spend more time with dad:

• Generational impact. A study published in the journal Parenting Science and Practice reports that patterns of father involvement and the quality of father-child relationships tend to be passed down across generations. Dads who are allowed to be more involved in their child’s life will, in turn, raise sons who go on to be dads who are more active in their own children’s lives. In other words, the current relationship is impacting the future ones.

• Healthier societies. Fewer children raised in nuclear fami

lies are considered to be in poor health. Research published in The Linacre Quarterly showed that 12% of children raised in a nuclear family were considered in poor health, compared to 22% of children of a single parent.

• Financial stability. According to research published in The Linacre Quarterly, custodial mothers lose up to 50% of their household income and are more likely to receive public assis tance. The median income of divorced mothers is only 47% of married-couple households. Children living with their mothers are more likely to be in poverty. When a dad plays an active role in a child’s life, there is likely to be more financial stability.

• Better educated citizens. In a study published in the jour nal Sociological Science, researchers report that parental divorce lowers a child’s educational attainment. This is due to the decline in family stability, family income and the child’s psy chosocial skills. They report that a child’s emotional well-being declines, which harms their educational attainment.

• Overall better societies. Dads’ Resource Center shares studies showing that children who spend more time with their dad are less likely to commit crimes, use government assistance programs, and smoke and use drugs. They are more likely to finish high school and college and be contributing members of society when they become adults.

“We live in a time where men are more engaged and in volved in raising their children than ever,” said Dads’ Resource Center Executive Director Jeffrey Steiner. “Unfortunately, far too many able and willing fathers are being denied that op portunity. Their children, and our society, suffer greatly when this happens.”

Dads’ Resource Center was started by Myers, a father of eight and the founder and CEO of AccuWeather. The mission is to help combat the issues associated with children growing up without their fathers in the home. At its heart, the center is a child advocacy organization that aims to ensure that each child has the appropriate involvement and contributions from both parents.

For more information, visit dadsrc.org.

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