OR Today January 2024 by MD Publishing

AAMI

FDA Eyes Biological Evaluation Standards

LIFE IN AND OUT OF THE OR

Infection Prevention

Amber Eaglin, MSN, RN

PRODUCT FOCUS

SPOTLIGHT ON

EQ FACTOR

Using EQ for Training Success

WINTER 2024

SURGICAL SMOKE LEGISLATION UPDATE PAGE 40

CORPORATE PROFILE // PG 36

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OR TODAY | Winter 2024

contents features

SURGICAL SMOKE LEGISLATION UPDATE The drive to get surgical smoke evacuation legislation passed in more states is picking up steam.

The infection control market is

Innovative Medical Products (IMP) has

The ability to stand up and talk does

projected to register a CAGR of 6.5%

set the gold standard in its patient

not a trainer make.

from 2021-2026.

positioning devices and aids for

MARKET ANALYSIS

CORPORATE PROFILE

EQ FACTOR

decades and continues to be a leader in the ever-changing surgical field.

OR Today (Vol. 24, Issue #1) Winter 2024 is published monthly by MD Publishing, 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290. POSTMASTER: See address changes to OR Today at 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290. For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. © 2024

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Winter 2024 | OR TODAY

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contents features

PUBLISHER John M. Krieg

john@mdpublishing.com

VICE PRESIDENT

CONTEST

Kristin Leavoy

THIS MONTH'S WINNER

Win a $25 gift card! Simply go to ORToday.com/Contest and fill out the short form for your chance to win!

Dee Matejek Mena Regional Health System

kristin@mdpublishing.com

VICE PRESIDENT OF SALES Jayme McKelvey

jayme@mdpublishing.com

EDITOR John Wallace

editor@mdpublishing.com

ART DEPARTMENT Karlee Gower Taylor Hayes

RECIPE OF THE MONTH

ACCOUNT EXECUTIVES

Amber Eaglin, MSN, RN

Tex-Mex Sweet Potato Beef Skillet

Megan Cabot

SPOTLIGHT ON

Kameryn Johnson

Emily Hise

DIGITAL SERVICES

INDUSTRY INSIGHTS

Cindy Galindo

11 News & Notes 16 ACHC: What Every OR Manager Should Know About Construction in the OR 18 The Joint Commission: The Joint Commission Announces Sustainable Healthcare Certification for U.S. Hospitals 20 AAMI: FDA Eyes Biological Evaluation Standards 22 CCI: CCI’s 45th Anniversary and a Vision for the Future 24 HSPA: SPDs: Stay Ready for Accreditation Surveys 26 NIFA: The Brick and Mortar Issue 28 ASCA: ASCA Advocacy Helps Medicare Patients Access More Procedures

IN THE OR

Kennedy Krieg

EVENTS Kristin Leavoy

ACCOUNTING Diane Costea

WEBINARS Linda Hasluem

EDITORIAL BOARD

32 M arket Analysis: Infection Control Market Growth Continues 33 Product Focus: Infection Prevention 36 Corporate Profile: Innovative Medical Products (IMP)

Justin Fontenot, DNP, RN, NEA-BC, FAADN Assistant Professor of Nursing at UL Lafayette Natalie Lind,

OUT OF THE OR

44 Spotlight On: Amber Eaglin, MSN, RN 46 Health 48 Fitness 49 EQ Factor 50 Nutrition 52 Recipe

MD PUBLISHING | OR TODAY MAGAZINE

Education Director for the Healthcare Sterile Processing Association, HSPA

1015 Tyrone Rd., Ste. 120 Tyrone, GA 30290

Pat Thornton,

800.906.3373 | Fax: 770.632.9090

Periopeartive Consultant

Email: info@mdpublishing.com www.mdpublishing.com

Dawn Whiteside, MSN (Ed), RN, NPD-BC, CNOR, RNFA, Director of Education, CCI

PROUD SUPPORTERS OF Julie Williamson, BA

54 Index 8

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Director of Communications, HSPA

OR TODAY | Winter 2024

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IMMERSE YOURSELF IN THE WORLD OF AMBULATORY SURGERY

Nashville, TN • March 9 - 12, 2024 For professionals in ambulatory surgery, AORN Global Surgical Conference & Expo offers two distinct journeys: the Ambulatory Hub at the main conference, tailored for clinical RNs working in outpatient facilities; and the Ambulatory Track at Leadership Summit, designed for ASC administrators, directors of nursing, and nurse managers. Here’s a look inside both. ASC NURSES Take this Journey

4 immersive days to engage with experts, explore the latest advancements, and gain insights into unique ambulatory challenges and opportunities. All in one dedicated space.

AORN Expo Ambulatory Hub Sessions You Won’t Want to Miss •

Eliminating Wrong Surgeries Through Improved Teamwork and Communication

•

The Psychological Aspect of Expansion and Growth in an ASC

•

Can Implicit Trust in Our ASC Team Lead to Medical Errors?

•

And Much More!

Discussions on regulatory compliance, patient safety, and evidencebased practice updates.

ASC LEADERS Take this Journey Ambulatory Track at Leadership Summit

Tailored sessions for ambulatory

surgery leaders to stay current, exchange insights, and grow your network.

Sessions You Won’t Want to Miss •

Infection Prevention in the ASC Environment of Care

•

Bringing a Total Joint Program to the Ambulatory Surgery Center Setting

•

Creating the Connection for Engaged Intra-professional Education at an ASC

•

And Much More!

*ACCESS TO THE AMBULATORY HUB IS INCLUDED WITH CONFERENCE REGISTRATION. REGISTER TODAY: www.aorn.org/surgical-expo

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INDUSTRY INSIGHTS

news & notes

New Breathable Surgical Gown Includes Instrument Pockets Cardinal Health has announced the U.S. launch of its SmartGown EDGE Breathable Surgical Gown with ASSIST Instrument Pockets, created to provide surgical teams safe and convenient instrument access in the operating room. Exclusively available from Cardinal Health, the gown is designed to hold one recommended instrument per pocket during surgical procedures, helping to provide handling efficiency and enabling clinical teams to focus on delivering safe patient care. SmartGown EDGE is made with chest pockets that can keep frequently used surgical instruments within easy reach while surgeons and clinicians operate across complex sterile fields. The gown’s unique pocketed design helps minimize potential contamination and unintentional instrument drops outside the sterile area. With SmartGown EDGE, surgical teams can store repeatedly used instruments in the gown’s pockets helping to reduce instrument handoffs or exchanges during a procedure, while promoting potential time savings and self-sufficiency. The creation of SmartGown EDGE is a result of a

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collaboration with Cardinal Health, Mayo Clinic and co-inventors Joseph Dearani, M.D., director of pediatric and adult congenital heart surgery, and Salim Walji, M.D., retired Mayo Clinic cardiothoracic surgeon. SmartGown is the leading brand of Association for the Advancement of Medical Instrumentation (AAMI) level 4 surgical gowns in the U.S., providing the highest barrier of protection against liquid and viral penetration. As the newest addition to the SmartGown portfolio, SmartGown EDGE is rated AAMI level 4 protection with the ability to resist high fluid exposure and bloodborne pathogens and is designed with unique breathable technology to keep surgical staff cool and comfortable. “Surgical teams are tasked to move quickly and expertly. Any deviations that prevent a smooth surgery, such as delays in instrument sterility or accessibility during the procedure, could create setbacks to the staff,” said Dearani. “We’re pleased to have developed a solution that helps minimize these operating room challenges and allows surgeons to keep procedures moving efficiently.”

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INDUSTRY INSIGHTS

news & notes

Periop Connect Returns in 2024 After a successful 2023 conference, the Periop Connect conference is set to return to Connecticut in October. The conference is supported by AORN Connecticut Chapter 0701. The conference is a must-attend event for perioperative nurses and those who work in or support an operating room with top-notch educational sessions, an exhibit hall and signature networking events. Attendees at the 2023 Periop Connect were asked to describe the conference in three words. Below are just some of the words they used to describe Periop Connect: • “Fun, informative, timeless” • “Informative and nice venue.” • “Educational fun classy” • “Excellent/Thought-Provoking/Fun”

• “Organized, fun, & educational.” • “Engaging, professional, connected” • “Empowering, Invigorating, inspiring” • “Interesting, educational, enlightening” • “Educational. Energizing. Empowering.” • “Informational, Interesting, Entertaining” The 2024 Periop Connect conference will be held October 25-26, 2024, at the Omni New Haven Hotel at Yale in New Haven, Connecticut. Located in downtown New Haven, just steps from the historic campus of Yale University and New Haven Town Green, the hotel puts you near everything. Enjoy walkable access to Union Station, and the rich history of Yale University’s extraordinary campus. Additional information, including a recap of the 2023 conference, is available at periopconnect.com.

Platform Helps Surgeons Avoid Serious Complications A new peer-reviewed journal article published in the Journal of Surgical Research shows that the KelaHealth’s Surgical Intelligence Platform was associated with a 21% reduction in acute kidney injury (AKI) and a 24% reduction in costly readmissions following colorectal surgery. AKI from colorectal surgery is associated with increased risk of death, shorter survival time, and development of chronic kidney disease (CKD), resulting in increased health care burden and unplanned readmissions costing $41 billion annually in the U.S. alone. These results further validate the KelaHealth platform’s ability to inject actionable intelligence into improved clinical outcomes, benefitting the surgical ecosystem across providers, payors and industry partners. The purpose of the study, conducted at Duke University Medical Center, was to determine if the individualized patient care pathways driven by this platform could leverage artificial intelligence (AI) to lower the rate of AKI and readmission following colorectal surgery. The study used the commercially available KelaHealth Surgical Intelligence Platform, powered by machine-learning software, to identify patients who were at high risk for AKI and 30-day readmission following colorectal surgery. Clinicians were made aware of patients’ risk status in real time through the electronic health record (EHR) and KelaHealth’s AI predictive

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platform prompted medically appropriate, patient-specific and cost-effective interventions to mitigate the associated risk. Many models are trained on either national or commercially available datasets, which limits their ability to identify local population-based nuances and tailor clinical recommendations to align with institutional best practices. In this study, KelaHealth’s AI platform analyzed 3,617 patient records, amassing over 200 variables per patient spanning demographics, clinical history and lab values. The AI model was customized to Duke’s unique patient population to tailor and hone predictive risk models specific to Duke’s patient population over a 5-year period. To guide surgical treatment, the KelaHealth platform was embedded within the traditional clinical workflow, which enabled surgical care teams to receive and interpret data in a prospective and anticipatory manner. The risk predictions provided by the platform highlighted recommendations for specific interventions designed to improve the outcome for each individual patient. A total of 665 underwent surgery during the treatment period; an additional 1,437 historical control patients were matched to 479 risk-based patients. After implementation of the platform, the authors found a 21% relative reduction in the rate of AKI (11.3% to 8.8%) and 24% relative reduction in rate of readmissions (12% to 8.9%).

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AAAHC Seats New Board Officers and Elected Directors Recently, the Accreditation Association for Ambulatory Health Care (AAAHC) announced its new officers and results for elected positions to its board of directors for the 2023-24 term. Supporting AAAHC’s 1095 Strong, quality every day philosophy, the board of directors will advocate for patient safety, provide strategic guidance on program development and administration, and share ideas to ensure continued success of the organization. “This is a strategically composed board whose members bring talents with nuanced expertise across a wide range of backgrounds and experience to our organization’s governance,” said Noel Adachi, president and CEO of AAAHC. “Together and with our dedicated staff, we can accomplish key initiatives that drive growth and foster dedication to ongoing quality improvement.” The new board officers’ one-year terms begin Nov. 6. While board members bring varied backgrounds, they share a common history of dedication to the provision of health care in the ambulatory setting. • Jan Davidson, MSN, RN, CNOR, Board Chair, has worked as a perioperative registered nurse for over 40 years. • David Shapiro, MD, Immediate Past Board Chair, contributes his extensive experience gained through many years as a department chair, medical director and board member of several ambulatory surgery centers. • Joy Himmel, PsyD, PMHCNS-BC, LPC, NCC, RN, Chair-Elect, has more than 40 years of experience in behavioral health working in hospital- and community-based programs, with over 25 years in college health and counseling. • Lawrence Kim, MD, Secretary/Treasurer, was reelected for a second term. Kim specializes in gastroenterology (GI) and has developed wide knowledge of AAAHC through experience as a surveyor and committee chair. The three elected directors, whose terms will expire in 2026, also assume their positions Nov. 6. Together they bring decades of experience in ambulatory care and health care management: • Kristine P. Kilgore, RN, BSN, was elected for a three-year term after assuming the position in 2021 due to an unexpected vacancy. She graduated from Grand Valley State University and started her nursing career working in a hospital on a medical-surgical unit for one year and then transitioned to the OR as the head nurse of the ENT, eyes, oral surgery, and plastics team for five years. • Traci McMillian, MD, is a board-certified family physician who has been in practice for 25 years. McMillian graduated from Wake Forest University School of Medicine in 1998 and initially practiced in a hospital-owned outpatient clinic before transitioning to college health 14 years ago. • Kelly Theodosopoulos, MBA, MBOE, BSN, has over three decades of health care experience, with more than 25 years in advanced leadership roles. She currently serves as chief clinical officer for SurgNet Health Partners, an ASC development and management company based in Nashville, Tennessee. For more information about AAAHC leadership, visit www.aaahc.org/ about-us/leadership/.

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ASCA Commends Updated Covered Procedures List Following release of the Centers for Medicare & Medicaid Services’ (CMS) 2024 final payment rule for ASCs and hospital outpatient departments (HOPD), the Ambulatory Surgery Center Association (ASCA) commended CMS for adding total shoulder surgery, total ankle surgery and a total of 37 surgical procedures to its ASC Covered Procedures List beginning January 1, 2024. “Adding these new codes to the list of procedures that ASCs can provide to Medicare beneficiaries,” said ASCA Chief Executive Officer Bill Prentice, “benefits both Medicare patients, who now have a lower-cost choice for obtaining the care they need, and the Medicare program itself, which will save millions of dollars as volume moves to the high-quality surgery center site of service.” Citing excellent outcomes data for total shoulder surgeries performed in surgery centers throughout the U.S. over many years, ASCA has long encouraged CMS to allow ASCs to perform these procedures for Medicare beneficiaries. Since Medicare policies also influence the policies other insurers put in place, ASCA expects the benefits of this decision to reach beyond the Medicare population and improve access to care and cost savings for patients covered by a broad range of insurers. CMS’ 2024 final payment rule also includes several other policies aligned with requests ASCA made to the agency over time. They include extended use of the hospital market basket, the same measure that HOPDs use, to set the inflationary update for ASCs; a decision not to finalize a proposal to readopt quality measure ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures, a measure ASCA raised concerns about in its comment letter on the proposed rule; delay of mandatory reporting for a new total hip and total knee quality measure, ASC-21; and retaining ASC 11: Cataracts Visual Function as a voluntary quality reporting measure.

Winter 2024 | OR TODAY

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INDUSTRY INSIGHTS

news & notes

FDA Grants KATE AI Breakthrough Device Designation for Early Sepsis Detection Mednition, a leader in clinical artificial intelligence (AI) health care solutions, has announced that KATE Sepsis has received Breakthrough Device Designation from the FDA, recognizing the AI-powered solution as a significant advancement in the early detection of sepsis. Sepsis is a life-threatening condition and stands as the number one cause of death in U.S. hospitals, the number one cause of readmissions, and the number one cost for hospitalizations. The difficulty of treating sepsis arises from challenges in early detection, where even a few hours of delay in the treatment can result in increased morbidity and mortality. “We are deeply honored to receive the FDA Breakthrough Device Designation for KATE Sepsis. This recognition underscores our commitment to advancing equitable care, improving patient outcomes and reducing risk for patients,” said Steven Reilly, chief executive officer at Mednition. “We believe every second counts in the fight against sepsis. KATE Sepsis represents a significant leap forward in detecting sepsis earlier and enabling clinicians to provide more effec-

OR TODAY | Winter 2024

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tive and timely treatment.” KATE Sepsis has achieved this designation by introducing novel and breakthrough technology that holds the potential to revolutionize early sepsis detection. KATE Sepsis demonstrated the ability to improve early detection of sepsis at emergency department (ED) triage over standard screening protocols by up to 118%. KATE Sepsis achieved this marked improvement at ED triage, before any laboratory diagnostic results are available. The challenge for the adoption of AI for sepsis detection has been demonstrating high sensitivity without sacrificing specificity, which can lead to dramatic increases in false positive rates and alert fatigue. KATE Sepsis predictions have a higher sensitivity with a 74% improvement for sepsis, 80% for severe sepsis, and 118% for septic shock when compared to the standard screening algorithm. This sensitivity improvement is achieved without a decrease in specificity, which is 95% for KATE Sepsis. More information on these results can be found in a preprint publication.

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The Joint Commission Issues Surgical Fire Alert Best estimates suggest that 90 to 100 surgical fires occur annually in the United States, creating safety hazards for patients, surgical teams and the operating room (OR) environment. Specifically, most surgical fires and burns are associated with the use of an electrosurgical device while performing head and neck surgery. The Joint Commission has issued Sentinel Event Alert, “Updated surgical fire prevention for the 21st century” to alert surgical teams to risk factors for surgical fires and to help identify strategies and actions to prevent them. Sentinel event data compiled by The Joint Commission suggest that leading factors contributing to surgical fires include shortcomings in teamwork and communication, work design, workforce and staff, and equipment. According to the Sentinel Event Alert, to overcome these shortcomings and reduce occurrences of surgical fires, staff should mind elements of the “fire triangle”: 1) oxygen, 2) ignition sources and 3) fuel. The Sentinel Event Alert suggests the following actions to prevent surgical fires: • Ensure that the pre-surgery time-out includes a robust fire risk assessment for each surgical and endoscopic procedure. • Anesthesiologists should maintain the local oxygen concentration at less than 30%, whenever possible.

• Carefully manage electrosurgical devices, light sources and cables, surgical draping and other risks during a procedure. • Provide training to operating room staff on how to avoid and manage fires and conduct fire drills. • Report all surgical fires into your facility’s incident reporting system. • Educate all OR personnel/team members about the risk of surgical fires. “Surgical fires can spark and quickly cause significant harm to patients, providers and the surgical environment,” says Herman A. McKenzie, MBA, CHSP, director, physical environment department, standards interpretation group, The Joint Commission. “Care must be taken, especially when using electrosurgical tools, to reduce the risk of fires. Recommendations in the Sentinel Event Alert, as well as The Joint Commission’s relevant requirements on fire prevention within the surgical environment, can support health care organizations as they develop fire prevention policies and procedures.” The Sentinel Event Alert also reviews related Joint Commission requirements and provides resources and references. The full alert is available at https://tinyurl.com/9wkjafhx.

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Winter 2024 | OR TODAY

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INDUSTRY INSIGHTS ACHC

What Every OR Manager Should Know About Construction in the OR By Richard Parker, MBA, CHFM, CLSS-HC, FASHE, FACHE

s technology and equipment advance,

A and new procedures are added, every

surgery department may confront demolition, renovation or construction at some point. Assessing risk prior to construction includes looking at utility requirements, air quality requirements, infection control, vibrations, noise and other hazards. OR leaders and staff need to evaluate risk from a big picture perspective and with a detailed focus on safety for the organization and its patients. A pre-construction risk assessment (PCRA) anticipates potential impacts of construction and establishes proactive plans to minimize undesirable situations for staff and patients.

What is a Pre-Construction Risk Assessment? A PCRA is an in-depth preparation document to define risks and determine the compensating measures that must be implemented so that the hazards and risks created by construction activities do not have a negative impact on patient care and staff work in adjacent areas. The PCRA will look at each construction hazard to establish its scope, timing and implications. When performing the risk assessment, it is also important to consider the impact on adjacent spaces including those above and below the work.

Six elements of the PCRA 1. Utility Requirements: Often, construction activities require interrupting utilities. For example, an electrical circuit may need to be shut off and this could affect multiple ORs. In this situation, the OR leader will define the acceptable time frames for the service interruption to avoid cancellation of surgical procedures. There may be ancillary impacts; bone and tissue freezers may need to be relocated during the outage, or equipment may need to be reset after the interruption, so it is

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ready for the next scheduled surgery. Air handling equipment providing HVAC is critical for patient and staff safety. If there is a planned interruption, this must be understood by the OR manager and scheduled. Evaluating further whether temperatures can be maintained within the manufacturer’s instructions for use through a service shut down will determine the impact on supplies and equipment. And an expected impact on air pressure relationships across critical areas, may demand compensating measures to protect items in sterile storage. This same thought process should be applied to plumbing to mitigate the impact on handwashing, steam used in sterilization and/or medical gases. 2. Air Quality Requirements: Containment barriers help protect occupied areas from the dust and fumes that may be generated by construction. These barriers may perform several functions; an infection control measure that separates the air from the adjacent spaces and a life safety measure to protect from fire or smoke. Air quality risk might also be identified in the infection control risk assessment, often resulting in the use of negative air fans to make the construction space negative pressure to the occupied space. If the PCRA identifies that some of the work will produce odors, this, too, requires a mitigation plan. This could be associated with new flooring, new paint, welding or other activities. 3. Infection Control: Construction workers have to get to their work location. If this involves traveling through other occupied space, an aggressive infection control risk assessment will include approving a path for workers, for new construction materials, and for demolition materials for disposal. Measures must be taken to make sure there is no impact on the clean and sterile environments while surgery continues to be performed. These might include a defined donning/doffing process, an anti-room to the construction area, tacky

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walk-off mats, covering trash and waste bins, and ongoing surveillance. The goal here is to make sure there is no evidence of construction outside of the construction area. 4. Vibrations and Noise: These risks are often coupled because it’s typically the same activity that causes both. An example might be percussive equipment used to remove flooring. The noise and vibration of that work will travel through slabs and walls to adjacent areas, disturbing and even disrupting OR staff work. It’s also particularly noticeable on floors below the construction area. Mitigation of this risk is most commonly accomplished by scheduling the activity and may include relocating patients or staff below or adjacent to the activity during that period of time. 5. Other Hazards: There may be other hazards created by demolition, construction or renovation work. Impacts on life safety systems, such as the fire alarm system or fire sprinklers are common. In those situations, a separate risk assessment process is initiated to determine alternate life safety measures (ALSM).

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These compensating measures may include revising the route of egress for OR staff when construction activities or containments block exit routes. If fire protection systems are out of service there may be a fire watch performed, or there may be additional fire drills to educate staff on the changes to the environment. OR leaders and staff should welcome and insist on being involved in the risk assessment process to inform construction staff about the needs of this specialized environment. And it’s not a one-time participation by OR leaders. If the project will continue over months, the OR leader should plan to have regular interactions with the construction team to make sure the surgery department remains safe. This includes providing adequate notice of construction activities and communicating any time measures that need to be changed. Richard L. Parker is associate director, physical environment and life safety at Accreditation Commission for Health Care, Inc. where he provides guidance to customers and surveyors in the ASC and hospital programs. Prior to joining ACHC served as Executive Director of Facilities for a 615-bed hospital system in Arizona.

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INDUSTRY INSIGHTS

Joint Comission

The Joint Commission announces Sustainable Healthcare Certification he Joint Commission recently announced a

T voluntary Sustainable Healthcare Certification

(SHC) program for U.S. hospitals, effective Jan. 1, 2024, acting upon requests from health care organizations that want to accelerate their sustainable practices and reduce greenhouse gas (GHG) emissions.

The SHC program, available to Joint Commission accredited and non-Joint Commission accredited hospitals and critical access hospitals, provides a framework to help organizations begin, continue or expand their decarbonization efforts and to receive public recognition for their commitment and achievements in contributing to environmental sustainability. The certification’s national standards and elements of performance establish needed structure, rigor and accountability to accelerate the industry’s growing sustainability efforts. The program includes setting priorities and governance for sustainability initiatives, creating baselines to measure three sources of GHG emissions, and developing an action plan to reduce them. Health care organizations that prioritize sustainability gain meaningful, lasting benefits such as cost savings, operating efficiencies, staff recruitment and retention, and potential payments and tax credits through recent federal incentives. Decarbonization also is an imperative for improving health care equity and patient safety, as the individuals least able to compensate for the effects of the climate are already burdened with adverse social determinants of health. “We want to work with the momentum of health care organizations leading the way in sustainability excellence – inspiring and guiding others that want to prioritize greener practices,” says Jonathan B. Perlin, MD, Ph.D., MSHA, MACP, FACMI, president and chief executive officer, The Joint Commission Enterprise. “Health care is one of the largest sectors in the United States and one dedicated to improving people’s health and well-being. Now is the time for The Joint Commission to take its place among other leading health care organizations to help accelerate environmental sustainability. Together, we can collectively reduce the health care sector’s carbon footprint and reduce hospital visits, illnesses, premature deaths and medical costs from severe weather events and other climate impacts.” “Today, there are severe and pressing operating challenges 18

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facing health care leaders and clinicians – but, despite that, the effort to mitigate and reverse climate change cannot be delayed,” says Don Berwick, MD, MPP, FRCP, KBE, president emeritus and senior fellow, Institute for Healthcare Improvement. “The effects of climate change pose an immense threat to human health, and it is incumbent on all of us to accelerate sustainable practices and reduce greenhouse gas emissions within health care. Fortunately, recent federal legislation that allows for expanded payments and tax credits makes massive new resources available to health care organizations willing to take advantage of that opportunity.”

Industry leaders rally for sustainable health care “At Parkland Health, we recognize the role that climate plays in health,” says Frederick P. Cerise, MD, MPH, president and chief executive officer, Parkland Health. “Climate change contributes to air pollution, extreme temperatures, severe weather and more. Such stressors tend to impact different populations differently. As a result, the most vulnerable populations tend to experience the worst impacts from these changes. At Parkland, we are a public health entity, and we are focused on underserved populations. Sustainability is an area that makes sense for us to pay attention to, both from a public health perspective and from a health care equity perspective.” Other health care leaders and innovators of all sizes and geographies care deeply about the future of their communities, their organizations and the world. To hear from some of them in their own words, including representatives from CommonSpirit Health, Parkland Health, Providence, the American Hospital Association and the Ohio Hospital Association, please visit jointcommission.org/our-priorities/ sustainable-healthcare. The Joint Commission also has launched an online Sustainable Healthcare Resource Center. The Resource Center provides key strategies, tools, literature, videos and links to help organizations get started on sustainability, as well as innovative solutions for those that have already taken steps to reduce their carbon footprint. It can assist hospitals as they prepare for SHC and serve as a forum to share and learn from others. Hospitals can begin working toward certification immediately and apply as soon as Jan. 1, 2024. Prior to this formal launch date, interested hospitals may complete a pre-application form. WWW.ORTODAY.COM

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INDUSTRY INSIGHTS AAMI

FDA Eyes Biological Evaluation Standards he U.S. Food and Drug

T Administration (FDA) has

been actively engaged in the development of standards that medical device manufacturers use as their reference for conformance to FDA guidance. This is especially true for standards that address requirement for biomaterials used in medical devices that come in contact with the body. Last year, AAMI hosted its first Biological Evaluation Standards Week, which brought together over 150 AAMI members, regulators and industry representatives to review the biological evaluation standards working program under the AAMI Biological Evaluation Committee and its 18 affiliated working groups. The week’s events fostered dialogue on further harmonizing biocompatibility testing in the U.S., which fits with the FDA program on biocompatibility presented on the last day of the week-long event. FDA representatives offered an update on the agency’s actions and guidelines for manufacturers, including a discussion on conformity assessment of biocompatibility testing. Past FDA action related to biocompatibility includes a draft guidance published in October of 2020, Select updates for biocompatibility of certain devices in 20

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contact with intact skin. According to Jennifer Goode, biocompatibility program advisor for the FDA and co-chair of the AAMI Biological Evaluation Committee, this guidance will likely be published within the FDA’s target of a three-year interval between the first draft and final version. In short, the situation continues to develop, and further information and explanation from the FDA is expected soon. The discussion also turned to the use of the 1.25 cm2/ml extraction ratio for elastomers as part of the U.S. recognition of the international standard, ISO 10993-12:2021, Biological evaluation of medical devices — Part 12: Sample preparation and reference materials. Current guidance from ISO 10993-12:2021 includes a revision in Table A1 and Clause 10.3.4. Table A1 no longer includes the 1.25 cm2/ml extraction ratio for elastomers with a thickness of less than 1.0 mm, and clause 10.3.4 has been revised to indicate that use of this ratio for any thickness component is only appropriate, if justified. Goode stated that when this revision to ISO 10993-12 was published, test labs participating in the ASCA program were asked to update their procedures to address how they were going to conform to this standard. “We decided at the time if they wanted to use it for thickness

greater than 1 mm according to the prior revision of the standard that would be fine and we would accept that,” she said. “However, we knew there might be some cases where it would be appropriate to also use it for elastomer devices or components that were less than .5 mm thick or components between .5 and 1 mm thick.” Providing an example of such an appropriate use, Goode said that using the 1.25 cm2/ml extraction ratio could be justified for elastomeric devices less than 0.5 mm thick, or of thicknesses between 0.5 to 1 mm when extraction is conducted at a higher surface area to extraction volume ratio, such as 6 cm2/ml or 3 cm2/ml, and results in the absorption of the entire extract volume or there is too little residual volume to conduct testing. That said, if a manufacturer uses the 1.25 cm2/ml extraction ratio for thicknesses of greater than 1 mm, they do not have to provide justification for that use. Cumulative use determinations also featured prominently in the discussion. Drafted revisions of ISO 10993-1, Biological evaluation of medical devices — Part 1: Evaluation and testing within a risk management process, are currently under consideration by the member bodies of ISO/TC 194, (the International Organization for StandardizaWWW.ORTODAY.COM

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tion (ISO) technical committee on biological evaluation of medical devices). Goode requested input on language included in the revised standard regarding “cumulative use” and “total exposure period” and asked how these definitions would impact manufacturers and test labs. Proposed changes to ISO 10993-1 are expected to define various levels of exposure based on the number of days elapsed between first and last use of a medical device. Considerations for cumulative use determinations will include how any changes in terminology and duration of contact impact biocompatibility evaluation, and how definitions are derived. Goode particularly focused on the importance of clarifying “cumulative use.” Invoking a hypothetical case where medical device use is catalogued as 30 minutes of use twice a day, and then added up to avoid breaking the 24-hour threshold, Goode indicated that adding up minutes may miss an important longer-term assessment. It would be a missed opportunity for data, she explained, that could be important for biological risk analysis. However, even with cumulative use as a baseline principle, there are still several issues that the experts

from AAMI’s Biological Evaluation Committee, which serve as the U.S. Technical Advisory Group to ISO/TC 194, will likely want to explore. These include: Greater clarity of definitions and requirements surrounding cumulative use requirements. The particulars of bioaccumulation, and how dosage may be a more pertinent concern than exposure over time. The extent to which relying on cumulative use thresholds exists in tension with offering clear definitions of categories like infrequent use. Whether caution is merited, and if treatment intervals are not the right metric for select medical devices. How different government agencies characterize frequent vs. infrequent use, and any need for consensus and coordination. Whether future guidance documents that clarify ISO’s standards might be useful and appropriate. Ultimately, the Biological Standards Week provided a great opportunity for AAMI members and industry players to interact with regulators and gain some clarity on FDA’s priorities on biocompatibility and some idea of what the future might hold.

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INDUSTRY INSIGHTS CCI

CCI’s 45th Anniversary and a Vision for the Future By mellissa nosik s we gear up to commemorate

A Competency and Credentialing Institute’s

(CCI) 45th anniversary in 2024, I am filled with excitement, a deep sense of pride, and anticipation for the transformative journey that lies ahead. This milestone is not just a celebration of our past achievements but also a testament to our unwavering commitment to setting quality standards of practice for perioperative nurses. It is with pleasure that I get to share with everyone a peek behind the curtain of what 2024 will bring.

specialized areas of practice in perioperative nursing. None of this would be possible without the collaborative spirit of our board of directors and the staff at CCI that drive us forward. We are forging stronger partnerships with key industry stakeholders, academic institutions, and professional associations to co-create innovative programs and initiatives that will propel us into the next era of supporting perioperative nurses. As an organization, inclusivity has always been at the core of our values, and we are committed to fostering a work environment where every voice is heard and respected. Our diversity and inclusion initiatives will continue to pave the way for a culture that values and celebrates the unique contributions of each and every member of our workforce. As we look ahead to the next chapter of CCI’s legacy, my vision remains steadfast – to uphold our commitment to excellence, foster a culture of continuous learning and improvement, and continue to be the driving force behind quality standards of practice for perioperative nurses. Here’s to 45 years of excellence, and to many more years of empowering our nurses and uplifting the standards of our industry. Together, let’s shape a future that is not just successful but also deeply impactful and meaningful for all.

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In the spirit of embracing technological advancements and enhancing accessibility, we were thrilled to recently launch our new user-friendly website. This digital facelift is our way of ensuring that navigating through our array of credentials and resources becomes a seamless and enriching experience for all our dedicated nurses and for the public. March 2024 holds a special place in our schedule this year as we plan to bring together the esteemed past members of our organization’s board of directors at the AORN convention in Nashville, Tennessee. This gathering is more than just a nostalgic trip down memory lane; it’s an acknowledgment of the profound contributions of our volunteers that have directed CCI to where it is today as the certification entity for perioperative nursing. In addition, we have some exciting tributes to earlier times for the organization that we will share, but we also have some exciting surprises in terms of resources lined up for our community throughout the year. Expect a series of new media, educational resources for certificants and those pursuing their certification, and new micro credentials focused on

Melissa R. Nosik, Ph.D., BCBA-D, ICE-CCP, SHRM-SCP is the chief executive officer of the Competency & Credentialing Institute. Nosik has 25 years of experience practicing and overseeing organizations in the health care industry.

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INDUSTRY INSIGHTS HSPA

SPDs: Stay Ready for Accreditation Surveys By Monique L. Jelks, BA, MSOL, CRCST

t’s 8 a.m. on Tuesday morning at General Community Hospital in Anywhere, USA. The announcement comes over the hospital intercom: “Good morning! General Community Hospital welcomes The Joint Commission.” Following the announcement is the panic and scurry of hospital employees, some of whom disperse to obscure areas in their departments in hopes they are not called on by surveyors to answer any questions. Why do we panic this way? After all, we follow regulatory requirements (law), standards and guidelines, manufacturers’ instructions for use (IFU), and our hospital’s policies and procedures – or do we? What happens when we don’t?

Last-minute plans and pressures from leaders to “get ready” when a facility enters the window of an accreditation survey instills fear and reduces confidence in many health care workers. The bottom line is no one wants to be the person who gives the wrong answer or demonstrates a process that led to a citation because of the potential harm to patients, staff or visitors. One example of last-minute pressures is the leadership announcement on Friday stating accreditation surveyors will arrive on Monday. Such announcements prompt swift action but leave health care employees hustling to get ready. Many employees work overtime to review and clean up data, purge, organize and stock departments as though they are putting their homes up for sale. When this weekly hustle is met with a “no-show” accreditation 24

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survey that following Monday morning, the same announcement is made the following week, and again after that, until the surveyors finally arrive. When the scrambling and subsequent waiting occurs, the mindset of many health care workers shifts from “get ready” to “let’s just get it over already.” The practice of getting ready in place of staying ready is a result of unsustainable processes. Sterile processing departments (SPDs) are recognized as a vital partner in infection prevention and control; therefore, the SPD has become an increasingly important department for surveyors to evaluate. The type of health care facility will determine which accreditation organization will conduct the survey. The Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (TJC) are just two accreditation agencies approved by the Center Medicare and Medicaid Services (CMS) to evaluate the quality of work and services provided to patients within health care facilities. These accrediting agencies evaluate processes and procedures to determine if health care facilities are compliant with laws, standards, guidelines and professional recommendations, instructions for use (IFU) and the facility’s own policies to keep patients safe. One way to develop sustainable, high-quality processes and service in sterile processing is to develop and implement a continuous quality improvement (CQI) program. Developing a CQI program should follow a team approach to attain buy-in and successful outcomes.¹ An effective CQI program should include education and quality audits that will

support people and improve processes continuously.

EDUCATION ESSENTIALS Education is the foundation for successfully developing sustainable processes that produce high reliability for quality trays and services. Education requires knowledge of industry standards and relevant resources to support the ever-evolving, technical world of sterile processing. Developing the education component for the CQI program starts by documenting a learning agenda, which helps to organize and prioritize education plans.² The learning agenda should outline all reprocessing areas within the sterile processing department (SPD). All SPDs have three basic areas: decontamination, preparation and packaging (prep & pack) and sterilization (note: additional areas, such as high-level disinfection and case cart processing, will need to be added to the outline). Once the outline is documented, it is necessary to add the educational plan for each area. The education plan should cover process steps and automated equipment. Process steps are the sequence of steps technicians perform to achieve the desired outcome in a particular reprocessing area. For example, in decontamination, the first step in the process may be to receive contaminated trays, and the final step would be loading the washer or pass-through window. When planning the education for process steps, clear communication and understanding should be provided for which professional recommendation is being followed – such as the Association for the Advancement of Medical Instrumentation (AAMI) or Association WWW.ORTODAY.COM

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of periOperative Registered Nurses (AORN). For the education plan to be effective, knowledge of regulations, standards and other professional recommendations, manufacturers’ IFU, and the facilities policies must be included in the plan for each respective area. Automated equipment, such as steam sterilizers and ultrasonic machines, will require education on the manufacturer’s IFU. No matter the reprocessing area, a review of the facility’s policy should be part of the education plan. Developing the education piece of the CQI program is the simple part. Implementing a CQI program is where the challenge begins for many SP leaders. Many SPDs function without a dedicated department educator, making it even more challenging to implement a successful CQI program. For departments without a dedicated SP educator, the department’s leaders must find creative ways to implement educational sessions. This is where the perfect opportunity presents itself to collaborate with infection control professionals (IP) within the facility. Infection prevention and the SPD both share the mission of preventing the spread of infectious microorganisms. Many IP professionals help to write facility policies and can reliably navigate regulatory standards to ensure SP is compliant with standards. Another creative way to implement a successful CQI program without a dedicated educator is to enlist shift leaders and frontline technicians to host education sessions that focus on the area where they are high-quality performers. Allowing high performers an opportunity to share their knowledge and shine can help to build a stronger team that fosters encouragement and engagement and leads to a sustained culture of learning and sharing. Education must also be provided routinely, not merely as a result of a poor outcome. Currently, many SPDs follow an annual educational plan, with the entire department provided with refresher education about certain aspects of sterile processing. The concern with this limited approach is that it’s fleeting. The annual plan is reflective of the tri-annual survey WWW.ORTODAY.COM

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visit where nothing is done to ensure standards are maintained until the announcement is made that “The Joint Commission is coming!” SPDs that follow the annual education plan may only receive additional education when a new instrument, device or equipment is purchased or when something goes wrong that requires a review of process steps, policies and IFU. Routine education, on the other hand, can reduce the risk of failure and poor outcomes. Education should be viewed and managed as an investment process that yields high-reliability outcomes continuously.³ Educated technicians are confident technicians who perform reliably and consistently. To change the culture from “get ready” to “stay ready,” the architecture around education must change. Scheduling routine educational sessions (weekly or monthly) is an effective way to develop confident technicians and a culture of learning and sharing that is necessary for maintaining continuous quality improvement.

QUALITY AUDITS CRITICAL We must remember that we can’t improve what we don’t review. Measuring the effectiveness of education is done by inspecting the quality of work after learning. Effective learning leads to high-quality outcomes and better problem-solving skills.² Conducting audits is about seeking to understand compliance.¹ Are we highly reliable and compliant or are there process deviations and opportunities for education? Some of the best technicians can misunderstand processes and, in return, teach their misunderstood process to another technician, which leads to a standard deviated process. Performing routine audits is the key to a “stay ready” culture. Process and product audits are two types of audits that can be performed in the SPD to ensure processes performed and products produced are of the highest standard and quality to keep patients safe. Process audits entail observing technicians while they perform processing steps. Product audits involve inspecting sterile devices/

trays before they leave the SPD. Audits should remain simple. This can be done by creating a checklist of all important factors to confirm compliance for each reprocessing area and for each type of sterile package. A sterilization process audit checklist, for example, may include the biological test documentation step to confirm the biological test and control have the same lot number. The product audit check-sheet would require the inspection of various package types (rigid, wrapped, pouched) and sterilization method. This checklist may also include compliance factors such as proper placement of external and internal indicators, cleanliness, organization and accuracy of tray contents. Audit results should be shared, and the positive outcomes must be celebrated to maintain engagement.¹ How often audits are done and who performs them will depend on the level of productivity and leadership structure.

CONCLUSION Preparing for an accreditation survey must never be done in a panic or at the last minute. SP leaders should aim to change the culture of their department from “getting ready” to “staying ready” by developing a successful CQI program where education and audits are in place to a culture of continual learning and sharing, and where technician confidence, encouragement and engagement are promoted and celebrated. – Monique L. Jelks, BA, MSOL, CRCST, serves as Sterile Processing Educator for Georgia’s WellStar Douglas, West Georgia, Acworth, KUP, East Cobb, Windy Hill & Paulding Hospitals. She is also the current president of the Healthcare Sterile Processing Association. References 1. Brenig-Jones, M., & Dowdall, J. (2018). “Lean six sigma for leaders: A practical guide for leaders to transform the way they run their organization.” Wiley. 2. Watkins, M. (2023). “The first 90 days: Proven strategies for getting up to speed faster and smarter.” Harvard Business Review Press. 3. Greene-Golden, S., Cherry, K., Price, L., and Combs, S. (2018) “WI.L.D. What I Learned During the Pandemic.” Winter 2024 | OR TODAY

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INDUSTRY INSIGHTS NIFA

The Brick and Mortar Issue By James X. Stobinski olly Gamble, in a recent article in Becker’s Healthcare Review (2023), spoke to the Brick and Mortar Paradox facing American health care. Gamble refers to entities invested in buildings and infrastructure used in the provision of American health care today and in the near future.

An evolution to virtual care and a shift of health care away from a physical location speaks to the brick and mortar issue at the center of Gamble’s article. This transition in care was jump-started during the COVID-19 pandemic and shows no sign of re-trenching. Two things are clear however, inpatient care and the infrastructure needed to support it is not going away soon but more health care is being delivered outside traditional settings. These facts bring us to a conundrum in health care planning. For the near future we will still need the physical buildings such as hospitals and clinics which are so familiar to current providers who trained in such facilities. Gamble, referencing data from the consultancy Sg2, tells us that the case mix index (CMI) is up 5% over the past 4 years and length of stay, a key financial benchmark, is also up over 10%. Thus, those who are receiving care now in a hospital are sicker, require more complex care and stay longer in the facility once admitted. For these patients, a physical space such as a hospital is needed now. The amount of brick and mortar needed to deliver American health

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care in its present state is influenced by many factors. We must also acknowledge that not all current health care facilities are used at optimal capacity. There is a relative oversupply in some areas/regions secondary to recent population shifts. I have spoken to the closures of rural health care facilities in other columns, a trend accelerated by ongoing merger and acquisition activity. Reports of closures of rural facilities and bankruptcies are common occurrences in sources such as Becker’s Healthcare Review. Gooch (October 2023) spoke to this very recently as hospitals were realigned in Oregon. More American health care is shifting away from hospitals to ambulatory settings which may leave a hospital with excess capacity within their building. In example, many hospitals invested in inpatient facilities to support orthopedic and spine procedures which formerly had longer postoperative inpatient stays. As technology and surgical procedures are refined more of these cases are done in the ambulatory setting leaving the dedicated hospital sites underutilized. A shift to telehealth and new models of care also has implications for the facilities needed to deliver health care. As technology evolves more care can be delivered in a home setting with the workforce, such as nursing staff, being physically distant from the patient. It is plausible that some patients will engage with a facility for an urgent episode of care and then return to their home to be monitored by a remote workforce versus being admitted to a hospital. This scenario summarizes the dilemma for American health care. How do

we plan long term for rapidly evolving health care? There are multiple stakeholders in play and not all of those stakeholders are pulling in the same direction. Strategic planning in this environment is a challenging, high-stakes endeavor. There are implications for the availability of surgical care as operating rooms are expensive to build and once built have high fixed costs. There are also implications for workforce planning as we must also educate the health care workforce with an eye to the future. New training sites and experiences may be needed for the American health care of the future. The brick and mortar paradox which is manifesting at present has numerous implications for the future of our health care system. – James X. Stobinski, Ph.D., RN, CNOR, CNAMB(E), CSSM(E), is the director of education with the National Institute of First Assisting.

References • Gamble, M. (OCT 16, 2023). Hospitals’ brick-and-mortar paradox. https://www. beckershospitalreview.com/capital/hospitals-brick-and-mortar-paradox.html?utm_ medium=email&utm_content=newsletter • Gooch, K. (October 23, 2023). PeaceHealth files layoff notice ahead of Oregon hospital closure. https://www. beckershospitalreview.com/finance/ peacehealth-files-layoff-notice-ahead-

of-oregon-hospital-closure. html?origin=BHRE&utm_ source=BHRE&utm_ medium=email&utm_ content=newsletter&oly_enc_ id=4467F0926923B3Y

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INDUSTRY INSIGHTS ASCA

Advocacy Helps Medicare Patients Access More Procedures By Bill Prentice SCA is ringing in the New Year with

A optimism that changes in the Centers for

Medicare & Medicaid Services’ (CMS) final 2024 ASC and hospital outpatient department (HOPD) payment rule will lead to increased Medicare beneficiary access to surgery centers. To keep the momentum going, we need all members of the ASC community to join us as we continue to advocate for surgery centers and their patients.

What Happened? CMS finalized many of the policies contained in the proposed rule circulated last July and several others the proposed rule did not address but for which ASCA had been long advocating. Among the latter were the addition of 11 significant procedures to Medicare’s ASC Covered Procedures List (ASC CPL), including total shoulder arthroplasty, total ankle replacement and a thyroid procedure. Combined with 26 dental codes that CMS included in its proposed rule, the agency’s decision means that, as of January 1, 2024, ASCs can now provide a total of 37 procedures to Medicare beneficiaries that they couldn’t offer these patients before. (You can learn more about all the procedures added and the other changes the rule puts in place online in ASC Focus magazine’s Digital Debut column “ASCA Advocacy Achieves Victories in 2024 Final Payment Rule.” ASCA members can learn more about the impact of the new rule on their facility under the Medicare Resources tab on ASCA’s home page. Physicians have been performing total shoulder and total ankle procedures on an outpatient basis for private pay patients and seeing outstanding results in HOPDs and ASCs for many years. Multiple studies demonstrate the high level of patient satisfaction and low level of complications physicians see when they perform these procedures in the outpatient setting, especially in surgery centers.

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CMS Decision Supports Patients, Providers, Medicare and Others For patients, CMS’ decision to add these new codes will mean improved access to care and to the many benefits ASCs offer, including high-quality outcomes, a patient friendly experience and often significant cost savings. For the Medicare program and taxpayers, as these procedures continue to migrate from the more costly inpatient setting into surgery centers, CMS’ decision could quickly translate into millions of dollars of savings each year in addition to the billions of dollars ASCs already provide to Medicare annually. Physicians, too, will benefit. By allowing physicians to perform these procedures on appropriate Medicare beneficiaries in surgery centers, surgeons will be able to bring more of their patients to the site of service they prefer – the ASC, providing greater control over scheduling. Since private insurance providers often build their policies on Medicare’s, private insurers and their beneficiaries can also expect to benefit from expanded access to these procedures in surgery centers and the high-quality, lower-cost care provided there.

Other Good News The new codes added to the ASC-CPL aren’t the only piece of good news for surgery centers in CMS’ final rule. CMS also moved total shoulder surgeries into a different Ambulatory Payment Classification (APC) category with a higher reimbursement, ensuring that more ASCs can afford to provide these procedures to Medicare patients. It also finalized its plan to extend the use of the hospital market basket as the inflation update factor for ASCs for an additional two years. ASCA advocated for that extension, seeing it as an important step toward more closely aligning ASC and HOPD payment policy and eliminating the growing disparity between ASC and HOPD payments that has occurred in the past. Two changes CMS adopted to its quality reporting program also reflected requests from ASCA and its

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members. First, CMS decided not to finalize its proposal to readopt ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures, a quality measure ASCA expressed concerns about in comments it submitted on the proposed rule. CMS also agreed to push back mandatory reporting for a year on a new measure it introduced in the final rule: ASC-21: Risk-Standardized Patient Reported Outcome-Based Performance Measure (PROPM) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) in the ASC Setting (THA/TKA PRO-PM).

Next Up Although surgery centers are celebrating several of the decisions CMS made in its 2024 final rule, now is not the time to let up. As many of you reading this column already know, significant changes in CMS’ payment policies don’t come easily or happen overnight. ASCA has spent years working with our members compiling data, meeting with CMS officials, talking with members of Congress and working with the media to build support for expanding

Medicare’s ASC-CPL to include total shoulders, total ankles and many of the other procedures the agency decided to add in 2024. ASCA has also been working with CMS over many years to try to make its ASC quality reporting program meaningful, useful to patients and less burdensome for surgery centers. Meanwhile, conversations and hearings in several key health care committees in Congress this past year have focused on issues that could negatively impact surgery centers. Some of the topics raised include cost reporting, site-neutral payments, the elimination of facility fees and price transparency. The ASC community, with leadership from ASCA and our members, needs to be involved in these conversations to make certain that any policy recommendations that result take the needs and specialized interests of surgery centers into account. If you work in a surgery center, one of the most important things you can do to be involved in ASC advocacy is to make sure your facility is a member of ASCA. Please get in touch with ASCA Government Affairs Manager Maia Kunkel at mkunkel@ascassociation.org to find out about other ways you can participate.

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www.milestonemed.com || 866-995-5300 || info@milestonemed.com

CE Credit Offering

Specimen Management: Reducing the Risk of Formalin Exposure Learning Objectives • Learn why proper specimen management is important in the perioperative environment • Be able to explain the difference between formaldehyde and formalin • Understand the risks associated with formaldehyde exposure • Review principles of formaldehyde safety in the perioperative environment • Learn about regulations, standards, and guidelines related to limiting formaldehyde exposure • Identify best practices for personnel safety and reducing the risk of formalin exposure

LEARN MORE

AORN EXPO Booth #2225 5

The bucket automatically centers and the built-in scale records the specimen weight.

The automatic dispenser lowers and the nozzle penetrates the one-way valve.

Formalin dispenses based on the preset, selected formalin/specimen weight ratio.

Close the valve cap for additional safety during transportation and to protect the operator.

weight. scale records the specimen

valve. penetrates the one-way

ratio. formalin/specimen weight

protect the operator. transportation and 12/1/23 to 9:39 AM

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IN THE OR

market analysis

Infection Control Market Growth Continues Staff report he infection control market is

T projected to register a CAGR

of 6.5% during the forecast period (2021-2026), according to Mordor Intelligence.

The infection control market is primarily driven by the high prevalence of nosocomial infections and the growing number of surgeries that require control measures to stop spreading, a Mordor Intelligence summary report states. According to the Centers for Disease Control and Prevention (CDC), about one in every 20 patients admitted for treatment will develop a nosocomial infection. Hospital-acquired infections result in more than 99,000 deaths each year. The lack of awareness regarding infection control and stringent regulatory requirements are anticipated to impede market growth. However, the government and non-government organizations’ initiatives regarding infection control, coupled with the growing control measures by the health care providers in hospitals, are expected to drive the market growth. For instance, in January 2020, The Ministry of Health and Population has launched the second phase of infection control initiatives in nine governorates of Egypt. Sterilization is important to control

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infectious diseases that may exist everywhere in hospitals or health care facilities, and it is debatable whether antibiotics can control such an extensive attack. The sterilization products and services segment under the product and services segment is anticipated to have lucrative growth owing to the increasing need to reduce hospital-acquired infection and extensive use of sterilization equipment in the health care settings. According to the World Health Organization (WHO), at least 30 new diseases emerged in the last 20 years, and infectious diseases kill 17 million people every year. Moreover, an increasing number of surgeries, increasing prevalence of infectious diseases and growth in the health care industry are anticipated to boost the market growth over the forecast period. In the end-user segments, the hospital is anticipated to have a significant growth due to the increasing adoption of infection control products due to increasing number of patients suffering from COVID-19 and stringent regulations by the respective governments to control the infections. North America is anticipated to have significant growth owing to wellestablished health care infrastructure, high adoption of infection control technologies and the presence of the key market

players in the region. Furthermore, the initiatives are taken by the government authorities in infection control and recent product launches. For instance, Getinge AB has launched a new 9100E Cart Washer in the United States for the health care industry. On the other hand, the Asia Pacific region is anticipated to have lucrative market growth due to the growing health care industry, increasing disposable income and expanding health care providers’ investments in infection control. Moreover, infection control initiatives and the growing number of hospital-acquired infections in the region are anticipated to boost the market growth over the forecast period. The global infection control market is moderately fragmented and competitive. Market players are focusing on new product launches, product innovations and geographical expansion to strengthen its market share. Global Market Insights (GMI) is another research firm that predicts market growth. “Infection control supplies market size was worth over $34 billion in 2022. Driven by the rising incidence of chronic ailments globally, the industry could grow at over 6% CAGR from 2023 to 2032,” according to GMI.

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IN THE OR

product focus

Kenall

MedMaster MCRT MedMaster MCRT 24-inch luminaires allow designers to integrate more dramatic shapes and maintain design consistency throughout a facility, while also meeting stringent cleaning and infection prevention performance standards. It features a full, backlit LED array and a highdiffusion lens that provides a uniformly lit appearance, and standard IP64 and NSF2 rating without visible room-side fasteners. The MedMaster MCRT series is the only round troffer on the market to feature Kenall’s safe and continuous Indigo-Clean Visible Light Disinfection option. Other luminaire options include a low-voltage controller and a white or amber night light for patient room applications. For more information, visit kenall.com

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IN THE OR

product focus

Ruhof

ATP COMPLETE 2 For the cleanliness verification of surgical instruments, endoscopes, and surfaces, ATP Complete 2 by Ruhof is a cloud-based cleaning monitoring system used to help hospitals and other healthcare organizations achieve optimal standardized cleaning levels. Advanced features include smart handheld mobile platform, Wi-Fi connectivity, infinite users and test points, customizable dashboard, RFID and barcode reader, user friendly interface and more. The system enables staff to achieve continuous improvements in every department including endoscopy, sterile processing, OR, environmental services, etc.

Sylke

Sylke Silk Surgical Dressing Sylke is the first wound closure and dressing made of pure hypoallergenic silk fibroin, an emerging biomaterial studied to enhance wound healing and reduce bacterial growth. “SYLKE aims to revolutionize surgical wound care by eliminating medical adhesive-related skin injuries that lead to complications such as surgical site infections and poor scarring outcomes. Promoting complication free wound healing allows for the epidermal barrier to regenerate faster and serves as a natural method of preventing infections. We see a benefit to millions of patients and aim to decrease the financial burden on the health care system by bringing SYLKE to market,” says M. Mark Mofid, MD, FACS, an assistant professor of plastic surgery at The Johns Hopkins University School of Medicine and inventor of SYLKE. Learn more at sylke.com

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IN THE OR

product focus

Medline

Vantex Central Venous Catheter with Oligon Technology Medline’s Vantex Central Venus Catheter (CVC) has been on the market for over 20 years and features patented, broadspectrum, antimicrobial technology that reduces risks of colonization to improve patient safety and help prevent costly central line-associated bloodstream infections (CLABSI). The Oligon Technology inside and outside of the catheter is comprised of silver, platinum and carbon black; which allows for a time-released antimicrobial for maximum efficacy during indwelling period. The 2020 ASA Practice Guidelines for CVC insertion recommend the use of silver/platinum/carbonimpregnated catheters over uncoated catheters for most effective CLABSI risk reduction. The Vantex CVC meets ASA guidelines using time-release silver ions extruded throughout the body of the catheter, internally and externally, to decrease risk of catheter-related blood stream infection (CRBSI). A link to that full study is below. Along with the clinical benefits of this product, Medline designed this product intuitively to include features such as: a pressurerated catheter, pre-attached needleless valves to save clinicians time during setup, a soft tip catheter to reduce the risk of vessel perforation, clear extension lumens for better fluid path visualization, and easy-to-read lumen identification and gauge size on color-coded hubs. Learn more at https://www.medline. com/infection-prevention/antimicrobialcentral-venous-catheter/.

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Corporate Profile

Adapting to the Evolving Surgical Environment

Shown: De Mayo Adapt2Fit™ Modular Knee Positioner

Innovative Medical Products

Innovating to Support Orthopedic Service Lines Many ASCs and outpatient clinics

The orthopedic healthcare industry is moving forward on an ever-changing course, challenging sterile processing logistics in facilities performing orthopedic procedures for the first time, while also experiencing expanded adoption of advanced robotic technology in operating rooms around the globe. Specializing in surgical patient positioning, Innovative Medical Products, Inc., covers all these advancements. The positioning equipment provides another “pair of hands” to increase efficiency and convenience for the surgeon and surgical team.

report that the smaller autoclaves, limited storage space and smaller soak sinks present a variety of logistical and sterile processing challenges. While outpatient facilities are insisting on maintaining

resulting smaller footprint allows the positioner to fit in smaller autoclaves typically found at Outpatient Centers. When disassembled, the Adapt2Fit’s reduced size also allows it to be fully sub-merged in standard sinks and cleaning vessels in a single pass, saving SPD valuable time, money, and resources.

consistency in training and how they approach procedures, they need a new solution to overcome the limited resources in smaller facilities. The De Mayo Adapt2Fit™ Modular Knee Positioner, which solves these pain points with a two-piece baseplate that quickly separates the positioner down to half of its overall length, has created an instant impact in the OR, creating several benefits for the surgeon and their facility. When stored in

Shown: Adapt2Fit® stored in included Sterilization Tray

its standard sterilization tray, the 36

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In effort to accommodate longer

such as Stryker, Zimmer Biomet,

frames. In 1984, Innovative Medical

patient leg lengths and overcome

Smith + Nephew, and CUREXO.

Products became the gold standard

All De Mayo Knee Positioners

with their original IMP McGuire Hip

the Adapt2Fit to be the longest

use a boot to secure the leg to the

Positioner, many of which are still

positioner on the market, when

positioner. The posterior side of the

in use today. In 2001, IMP improved

assembled. The result is that the

boot includes a distractor block for

pelvic stability in hip positioning

Adapt2Fit is a full 2-7” longer than

use with our De Mayo Universal

with the assistance of orthopedic

previous models. The increased

Distractor to distract the knee joint

surgeon Ed De Mayo, MD. Together,

positioner length provides more

via an external force applied to the

they developed the De Mayo Hip

surface area for full flexion and

underside of the patient’s thigh with

Positioner® to support improved

extension of the knee, without

the leg positioned at 90 degrees of

accuracy of implant placement

moving the baseplate.

flexion. The distractor is controlled

during total hip procedures.

the space constraints, IMP designed

by the operating surgeon in the

IMP’s goal is to utilize initial

sterile field, enabling controlled

scientific data to better understand

distraction via a lever to create an

how rigid positioners behave in

unobstructed view into the joint

order to assist in stabilizing the

space between the posterior femur

pelvis and correctly matching the

and proximal tibia.

appropriate hip positioner to the

In the traditional use of the

surgeon’s procedure objective.

De Mayo Knee Positioner, the foot and ankle are secured in the boot. When the De Mayo Knee Positioner boot is locked into the traveling carriage, knee flexion/extension and varus/valgus motion are controlled Shown: Adapt2Fit Knee Positioner

The De Mayo Knee Positioner’s

in the surgical field. Research conducted by IMP investigated the use of the Universal Distractor to

redesigned carriage and locking

further stabilize the leg during the

system delivers on both easy

registration process employed by

removal and improved holding

the surgeon during navigated or

power, helping to make knee

robotic-assisted knee reconstruction.

While in the early stages of

surgeries easier for all types of cases,

The study results demonstrated

development, IMP conducted a

including bariatric. The patented

that the combination of these two

study at St. Mary’s Medical Center

ball and socket design provides the

devices improved stability of the

in San Francisco, California. The

surgeon with more precise control of

leg, over the Knee Positioner alone,

results of the study concluded

flexion, extension, tilt, and rotation.

to improve the reliability of the

that minimizing pelvic rotation,

registration process supporting the

an objective believed to improve

knee reconstruction.

implant placement accuracy during

Robotic Surgery Requires Improved Limb Stability and Access to the Knee Joint

total hip procedures, is directly

knee replacement surgery offers

Redefining Rigid Patient Positioning in Total Hip Reconstruction

greater value of the De Mayo Knee

Patient positioning during

Positioner due to its ability to

reconstructive hip surgery was

increase limb stability during total

traditionally accomplished using

knee procedures, when used with

various positioning aids, from bean

robotic systems from companies

bags to pegboards to rigid clamping

The introduction of robotic-assisted

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Shown: De Mayo Universal Distractor®

influenced by the positioning device used during surgery.

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Corporate Profile

IMP’s newest lateral positioner, the

maximize their initial investment.

Exact-Fit® De Mayo Lateral Positioner®,

Discounted or complimentary

delivered the best pelvic stability

upgrades, courtesy service loaners,

when compared to existing options.

repairs, and on-site training and

Customer-Valued Products Remains the IMP Focus

education services are just a few of the benefits that facility

IMP’s vision for success has

administrators will find helpful in

always been to collaborate with

protecting their initial investment’s

customers to design, manufacture,

value.

and distribute unique, innovative products where surgical patient positioning or supporting logistics has been problematic. IMP’s solutions to universal patient positioning challenges are developed through years of collaboration with busy orthopedic surgeons, marketleading orthopedic companies,

Shown: Exact-Fit® De Mayo Lateral Positioner®

and hands-on med/surg support teams. Ideas have been shared

MVP: IMP’s Value-Added Commitment Transforms into the Most Valued Partnership

have been extensively tested

environment. Having completed

As part of IMP’s shared commitment

during clinical trials to provide

ISO 13485 registration successfully

to its customers, Orthopedic facilities

maximum patient protection

in 2021 to expand IMP’s products

will now be able to gain special

from pressure sores and ulcers. By

outside of the US, the company is

access to IMP’s premiere partnership

consistently using IMP’s premium

now supporting surgeries in global

level service and support by using

patient protective pads, orthopedic

markets and the rapidly growing

genuine IMP patient protective pads

healthcare providers may reduce

outpatient facility networks in the US.

for each procedure.

liability by assuring that they meet

for product improvements with perceptive opinions on improving IMP’s patient protective pads

patient positioning in the surgical

MVP, otherwise referred to

AORN and AAMI standards for using

as “Most Valuable Partner,” is a

the manufacturer’s recommended

For more information, please visit

new program that helps facilities

pad as defined in the IFU.

IMPmedical.com.

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Designed to reduce the risk of surgical site infections*

Stabilizes the limb

FPO Now available in 2 different sizes for lower and upper extremities. *SteriBump’s unique sterile foam eliminates free fibers and the risk of cross-contamination

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COVER STORY

SURGICAL SMOKE LEGISLATION UPDATE BY DON SADLER

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he health hazards T of surgical smoke to patients and

perioperative personnel have been welldocumented. In fact, the U.S. Occupational Safety and Health Administration’s (OSHA) first alert about the potential dangers of surgical smoke was issued more than 35 years ago. However, OSHA never formulated regulations requiring hospitals and ASCs to eliminate surgical smoke plume. So, the focus turned to state legislatures instead.

Surgical Smoke Legislation is Spreading The good news is that the drive to get surgical smoke evacuation legislation passed in more states is picking up steam. In October, California became the most recent state to pass legislation requiring health care facilities to use all tools feasible to remove surgical smoke plume from the operating room. There are now 15 states with surgical smoke evacuation legislation on the books. Each year, approximately 10 state legislatures consider surgical smoke legislation, and legislation has been passed in five states each of the past two years. The following states have now passed surgical smoke legislation: Arizona, California, Colorado, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Missouri, New Jersey, New York, Ohio, Oregon, Rhode Island and Washington. In addition, legislation is currently under consideration in six states: Florida, Massachusetts, North Carolina, Pennsylvania, Texas and West Virginia. Richard Howard, North America

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sales manager with I.C. Medical, believes that surgical smoke legislation is important because it is often a precedent for requiring smoke evacuation compliance by health care facilities. “The use of smoke evacuation modalities has largely been at the discretion of the surgeon or the willingness of management to make them readily available,” says Howard. “Legislation is helping set the precedent that the use of smoke evacuation modalities is no longer a choice, but a requirement. This is putting all stakeholders – including nurses, hospital management and surgeons – on the same page.” The Association of periOperative Registered Nurses (AORN) has been active in helping get surgical smoke legislation passed at the state level, says Jennifer Pennock, AORN’s associate director of government affairs.

protections from harmful surgical smoke. “Since then, we have had numerous meetings with OSHA to discuss actions the agency may take to raise awareness of the workplace hazards of surgical smoke and encourage the use of surgical smoke evacuation systems,” says Pennock. Pennock adds that surgical smoke legislation is necessary because while many agencies recognize the hazards of surgical smoke and a few even go on to recommend evacuation, there are no national or statewide enforceable requirements for the evacuation of surgical smoke. “Many surgical facilities evacuate smoke during some procedures, but few evacuate consistently during all smoke-generating procedures,” says Pennock. “Nurses have little control over whether they are assigned to a smoking or non-smoking operating room.” Pennock notes that restaurant staff and flight attendants are now safe from cigarette smoke, while offices and most public spaces are now smoke-free. “Nurses and surgical team members deserve the same protection,” she says.

State-by-State Efforts Richard Howard North America Sales Manager at I.C. Medical

“AORN has concentrated on legislation at the state level to effect change and implement this critical workplace safety provision for as many OR nurses and their colleagues as quickly as possible,” says Pennock. During a national petition drive in 2021, AORN collected thousands of signatures for a petition urging OSHA to issue regulations requiring worker and patient

Ahnyel Burkes, DNP, RN-BC, NEA-BC, was active in getting surgical smoke legislation passed in Louisiana last year. “Surgical smoke exposure could fall under the general duty clause, which states that employees should be protected at work, but there needs to be specific laws and requirements,” she says. “This is why you’re witnessing a state-by-state effort to get surgical smoke laws passed.” According to Burkes, the Louisiana law defines surgical smoke plume as “the byproduct of using heat-producing equipment on

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COVER STORY tissue during surgery.” The law requires licensed health care facilities that perform surgical procedures using heat-producing equipment to adopt and implement policies for a surgical smoke plume evacuation plan to mitigate and remove the surgical smoke plume. “Compliance with the law will be verified by the Louisiana Department of Health through onsite surveys that are specific to surgical services, full licensing surveys, full recertification surveys and complaint surveys if allegations specific to surgical services are alleged,” says Burkes. Burkes lays out the playbook for getting surgical smoke legislation passed at the state level. It starts with gathering research about the negative impacts of surgical smoke, along with support from content experts like AORN. “Next is socializing the issue with other nursing groups to gain support, such as the Louisiana State Nurses Association, which later spearhead the effort,” she says. Existing legislation in other states was reviewed and meetings with stakeholders who might be impacted by the bill were held next, followed by finalization of the bill’s language.

Ahnyel Burkes DNP, RN-BC, NEA-BC

“Then, we gathered letters of support from other organizations and attended committee meetings to testify in support of the bill, bringing along content experts

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while simultaneously organizing grassroots support,” says Burkes. Brenda C. Ulmer, RN, MN, CNOR, was instrumental in getting surgical smoke legislation passed in Georgia in 2022. “I’m very optimistic that our legislation will have positive long-term effects in Georgia,” she says. “In fact, I think we’re already seeing this.” Ulmer tells the story of talking to a medical student during her annual physical exam: “The student asked about my background and I told him I did education on electrosurgery and surgical smoke. He said, ‘You know, there’s a law in Georgia about surgical smoke now.’ I just chuckled and told him that yes, I did know about it.” “In my mind, this is proof positive that a practice change has definitely occurred,” says Ulmer. Unfortunately, surgical smoke legislation in Texas suffered a setback recently when two bills passed hearing and made it to the floor for a vote. “However, time ran out before voting could commence and the bills died on the floor,” explains J.D. Buchert, M.Ed., MS, MSN(s), RN, CNOR, the president of the Texas Collaboration of periOperative Registered Nurses (TCORN). Buchert says this is the closest these bills have ever gotten to passage. “My biggest reason for advocating so heavily about surgical smoke legislation is simple: Because it’s the right thing to do,” he says. “As perioperative nurses, we want to help save lives and not be put in danger while doing it.” TCORN is now working with AORN to get surgical smoke evacuation placed in the state regulatory process. “We’re trying to maintain the verbiage of both bills and the integrity of the surgical smoke evacuation focus in the regulations,” says Buchert. “While our fingers are

crossed that this regulation passes, we will also continue to pursue the bills to make this state law.”

Jennifer Pennock Associate Director of Government Affairs at AORN

According to Pennock, surgical smoke legislation tends to be most successful in states with strong grassroots advocates who are committed to working on policy advocacy for multiple years and through legislative sessions. “To lay the groundwork for successful legislation, it’s important to engage with stakeholders early in the process,” says Pennock. “It’s also important to identify a strong bill sponsor in the House or Senate who will throw their political influence into the success of the bill, and to gain support from state nurses’ and hospital associations.”

Why Surgical Smoke is So Dangerous Approximately 90% of all surgical procedures generate surgical smoke and up to half-a-million health care workers are exposed to surgical smoke each year. The average daily impact of surgical smoke on the surgical team is the equivalent of inhaling the smoke of up to 30 unfiltered cigarettes. Surgical smoke contains more than 150 hazardous chemicals and carcinogenic and mutagenic cells. “It contains toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde, bioaerosols, dead and live cellular material, blood

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fragments and viruses,” says Pennock. In addition to the danger to health care workers, surgical smoke can also cause cancer cells to metastasize in the incision site of patients having cancer removal surgery. Babies born by C-section breathe in their parent’s surgical smoke at birth. While patient exposure to surgical smoke is short-term and relatively low risk, surgeons and other OR staff may be exposed to surgical smoke daily. At high concentrations, this smoke may cause ocular and upper respiratory tract irritation. In a study reported in the Journal of Clinical Nursing in 2016, 49% of nurses and 58% of surgeons reported experiencing headaches, 40% of nurses and 42% of surgeons reported watery eyes, and 49% of nurses and 28% of surgeons reported coughing due to exposure to surgical smoke. Nurses and surgeons also attributed sore throat, nausea, drowsiness, dizziness, sneezing, rhinitis and bad odors absorbed in the hair to surgical smoke. In fact, perioperative nurses report twice as many respiratory problems compared to the general population. The best solution to these problems is to safely and effectively eliminate surgical smoke by using a smoke evacuator device. “Evacuating the smoke from its source is vital,” says Howard. “We must effectively capture all of the plume directly from the source.” For surgical procedures generating a large amount of plume, a dedicated smoke evacuator, equipped with a ULPA filter, will be used. “Either a smoke evacuation pencil or handheld wand tubing will be connected to the smoke evacuator and positioned near the source of smoke generation,” Howard explains. For procedures generating a nominal amount of plume, the hospital wall suction system, equipped with a ULPA filter installed in-line, will be used. “A smoke evacuation pencil, pencil tubing adapter or handheld wand tubing will be connected to the suction device and positioned near the source of smoke generation,” Howard explains. Used filters with captured surgical smoke are disposed of as hazardous waste.

A Grassroots Movement With the current momentum, Ulmer is optimistic about the passage of more surgical smoke evacuation laws across the country. “These are grassroots movements led by nurses,” she says. “I believe this is a powerful message to nurses as they work to improve the operating room environment for health care workers and patients.” AORN provides ongoing education about surgical smoke, including the AORN Go Clear program. To learn more visit https://www.aorn.org/education/education-for-facilities/ surgical-safety-center-of-excellence/go-clear-awards.

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FAQS ABOUT SURGICAL SMOKE EVACUATION Q: HOW IS SURGICAL SMOKE EVACUATED? Surgical smoke can be safely and effectively evacuated by using a smoke evacuator device designed to capture smoke at the source. Such a device may be attached to the electrosurgical pencil being used by the surgeon.

Q: HOW LONG DOES IT TAKE A FACILITY TO GO SMOKE-FREE? It usually takes from six months to one year for a facility to work with its surgical team and suppliers to implement a smokefree program that works for all teams and specialty procedures performed facility-wide.

Q: HOW MUCH DOES IT COST TO IMPLEMENT A SMOKE-FREE PROGRAM? Operating rooms are already equipped with suction equipment that can be used to evacuate surgical smoke. Meanwhile, the cost for filters is minimal and the cost difference between traditional pencils and electrosurgical pencils with evacuators attached can be as little as a few dollars per pencil.

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SPOTLIGHT ON:

AMBER EAGLIN, MSN, RN INSTRUCTOR, UNIVERSITY OF LOUISIANA AT LAFAYETTE

By Matt Skoufalos hroughout her childhood, Amber Eaglin loved animals so much that she’d planned to pursue a career in veterinary medicine. Unfortunately for those dreams, during her first internship at a local zoo, she froze up around the miniature horse and started to have second thoughts.

Fortunately for Eaglin, she was living in Lafayette, which happened to also be home to one of the best nursing schools in the south: the University of Louisiana. With a slight adjustment of focus, Eaglin embarked on a course of study that became her path to the operating room. Among the first skills the program emphasized was “rewiring the way that you think,” Eaglin said, from time management practices to intensive research into community health problems. The academic intensity of the program was legendary, but its rigors produced nurses who were eminently prepared for their work in the field. “It’s a full bachelor’s degree program, so we learn everything about our patient,” Eaglin said, “not just the disease process, but the comorbidities, what we do to fix it, the medications and their contraindications, what we expect to happen, and, if it doesn’t work, what we do after that.” “It’s a tough time, a very intense school, but by the time they graduate, our students have a job ready to go,” she said. “There’s a lot expected of you, which is an important thing. Nursing isn’t just handing out medications and giving shots. It’s about what’s best for the patient and their healing process.” During a three-week summer program, in which she shadowed working nurses to observe their experiences in the workplace, Eaglin followed as her mentor navigated the ins and outs of the job: conflicts with patients, consultations with colleagues, managing med-

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ications and supplies, and the details around patients and their procedures. It was her first opportunity to be exposed to the pre-operative environment, patient recovery, and the operating room, where she felt like she had found her place. Eaglin loved it so much she returned for a paid internship the following summer, and after graduation, when she began working at a nearby regional hospital, she headed into the OR after building skills as a floor nurse. She handled bariatric and general surgeries, but specialized in the treatment of burn victims. “The hospital opened up a burn unit – one of the few in the area – and helped so many people close by instead of flying them out [for treatment],” Eaglin said. “We had cases every day, and it took up most of my morning every time.” As her career progressed, Eaglin honed her focus as an OR nurse, developing her understanding of the surgical team and how to support its goals. Although her work in the OR was different from performing bedside care as a circulating nurse, Eaglin nonetheless delivered perioperative patient education with the same bedside manner of a floor nurse as part of her work in that environment. “As nurses, you learn to work as a team,” she said. “We learn how to handle our six to eight patients, and how to manage all that, but you’re still the one doing most of the care for that patient. Then you go into the OR, and there’s so many things you need to know – some of the surgeon’s job, some of the scrub tech’s job, all the different equipment that needs to be used – it’s so much more of a group effort.” After years in the OR, Eaglin decided to pursue a master’s degree in nurse education at Lamar University, which she earned over three years, all while working full-time. Upon graduation, Eaglin went on to become an instructor at the University of Louisiana at Lafayette, and now enjoys the work of teaching the next generation of nursing students about what

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to expect from their careers. The guidance she offers nursing students is based in both her own practical experiences in the field as well as the academic curriculum. “You have to have a thick skin, because people will come at you sideways quite often,” Eaglin said. “And you have to be autonomous. You need to learn what needs to be done in a day so you can get it done as fast, efficiently, and as well as you can, because something will go wrong. Do what you need to get done, but prepare for things to go wrong.” Eaglin’s work in the health care field also influenced the vocational choices of her siblings. Her younger brother now works as a travel nurse, and her sister is a clinical pharmacist. She believes her perspectives in the field have helped clarify their expectations just as they have those of her students. “It’s a lot of un-thanked work, but we do it because we want to take care of people,” Eaglin said. “You’re not going into this for the money, because it’s not as great as you thought it was, and you’re not going into this for the glamour, because it’s not there. Go into it for a good reason.” Eaglin is the married mother of a four-yearold son, Sylvester, and is pregnant with twins. Her husband, Johnathan, is a youth pastor and educator, and together, the family is focused on raising their young children. When she’s not busy at work or home, she enjoys reading. She described the value of good fiction in helping her manage the variety of personalities she encountered in her nursing work. “You meet so many people in books who have backstories and perspectives; when I run into different patients it makes me think about where they’re coming from,” Eaglin said.

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OUT OF THE OR health

Extreme Heat Projected to Increase Cardiovascular Deaths ardiovascular-related deaths due to extreme

C heat are expected to increase between 2036

and 2065 in the United States, according to a study supported by the National Institutes of Health. The researchers, whose work is published in Circulation, predict that adults ages 65 and older and Black adults will likely be disproportionately affected.

While extreme heat currently accounts for less than 1% of cardiovascular-related deaths, the modeling analysis predicted this will change because of a projected rise in summer days that feel at least 90 degrees. This heat index, which factors in what the temperature feels like with humidity, measures extreme temperature. Older adults and Black adults will be most vulnerable because many have underlying medical conditions or face socioeconomic barriers that can influence their health – such as not having air conditioning or living in locations that can absorb and trap heat, known as “heat islands.” “The health burdens from extreme heat will continue to grow within the next several decades,” said Sameed A. Khatana, M.D., M.P.H., a study author, cardiologist and assistant professor of medicine at the University of Pennsylvania, Philadelphia. “Due to the unequal impact of extreme heat on different populations, this is also a matter of health equity and could exacerbate health disparities that already exist.” To generate these predictions, researchers evaluated county-level data from the contiguous 48 states between May and September of 2008-2019. More than 12 million deaths related to cardiovascular disease occurred during that time. Using environmental modeling estimates, they also found that the heat index rose to at least 90 degrees about 54 times each summer. Researchers linked the 46

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extreme temperatures that occurred during each summer period to a national average of 1,651 annual cardiovascular deaths. Some areas, such as the South and Southwest, were affected more than others, such as the Northwest and Northeast. Using modeling analyses to forecast environmental and population changes, the researchers looked to 2036-2065 and estimated that each summer, about 71 to 80 days will feel 90 degrees or hotter. Based on these changes, they predicted the number of annual heat-related cardiovascular deaths will increase 2.6 times for the general population – from 1,651 to 4,320. This estimate is based on greenhouse gas emissions, which trap the sun’s heat, being kept to a minimum. If emissions rise significantly, deaths could more than triple, to 5,491. For older adults and Black adults, the projections were more pronounced. Among those ages 65 and older, deaths could almost triple, increasing from 1,340 to 3,842 if greenhouse gas emissions remain steady – or to 4,894 if they don’t. Among Black adults, deaths could more than triple, rising from 325 to 1,512 or 2,063. In comparing current and future populations, the researchers accounted for multiple factors, including age, underlying health conditions and where a person lived. Most people adapt to extreme heat, as the body finds ways to cool itself, such as through perspiration. However, people with underlying health conditions, including diabetes and heart disease, can have different responses and face increased risks for having a heart attack, irregular heart rhythm or stroke. “The number of cardiovascular events due to heat affects a small proportion of adults, but this research shows how important it is for those with underlying risks to take extra steps to avoid extreme temperatures,” said Lawrence J. Fine, M.D., a senior advisor in the clinical applications WWW.ORTODAY.COM

12/1/23 9:40 AM

and prevention branch, in the Division of Cardiovascular Sciences at the National Heart, Lung, and Blood Institute (NHLBI), part of NIH. The authors described cooling approaches that some cities are using – planting trees for shade, adding cooling centers with air conditioning, and using heat-reflective materials to pave streets or paint roofs. However, more research is necessary to understand how these approaches may impact population health. “In addition to thinking about the impact of extreme temperatures in the U.S., this type of modeling forecast also foreshadows the impact that extreme heat could have throughout the world, especially in regions with warmer climates and that are disproportionately affected by health disparities,” said Flora N. Katz, Ph.D., director of the Division of International Training and Research at the NIH Fogarty International Center. Study Khatana SE, Eberly LA, Nathan AS, et al. Projected change in the burden of excess cardiovascular deaths associated with extreme heat by mid-century (2036-2065) in the contiguous United States. Circulation. 2023; doi: 10.1161/ CIRCULATIONAHA.123.066017.t

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OUT OF THE OR fitness

Strengthen Foundation to Ease Lower Back Pain By Miguel J. Ortiz f you wouldn’t buy a

I house with a weak

foundation, why would you try building on top of one? I see people all the time with weak or chronic lower back pain trying to do strength training. It is important, but if you avoid working on your foundation you’ll only cause more issues down the road. You might be thinking, well the foundation is your core. Wrong, your foundation is made up of your hips, and if your hips aren’t aligned or moving well then it will absolutely mess with your lower back, which involves your core. The stronger and more mobile the hips, the better the “house” will be on which it stands. So, let’s dive into some exercises that will ensure a stronger and more mobile foundation. Our first movement involves more mobility to ensure we lengthen before we strengthen. I recommend the 90/90 Hip stretch. (3x12 total) be done by using your hands on the ground with assistance, especially if your already pretty tight in your back. We’re attacking

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the hips directly by simultaneous stretching the hip flexors, adductors and glutes with a bonus rotation to provide lower back relief. The second movement also provides added mobility for the hips and preps the back for proper strength, the half kneeling cat cow (3x5each). This exercise is fantastic for prepping the back before taking on a load, like squats, carrying or upper body movements. The split position will allow you to open up the hips and realize how much you might favor one side over the other. Creating appropriate balance and symmetry within your hips will tremendously help with the ability to control alignment during strength training. Remember, if your exercises create any compensatory patterns during lifts, it will constantly affect your lower back. So, these first two mobility exercises are a great way to get aligned before going into other strength training and core movements. The last exercise is essential for a proper mind-muscle connection. Although it looks like a simple

movement, it’s the way you do it that makes the the floor glute bridge (3x15 reps) difficult. Without proper glute activation, which is the foundation of the “house” or core, your back will constantly be in compromised positions. This exercise is meant to be done as slow as possible and pushed to its fullest range of motion. On the way down or during the eccentric part of the movement is where the magic happens. At the highest part of the motion, this should not be felt in your lower back, if it is then you can tell that your glutes aren’t being activated appropriately. While you lower your hips to the floor, the goal is to have one vertebra touch the ground at a time. This will force you to relax the glutes and start activating your core. This core activation practice will give you the proper strength and confidence needed to perform other movements. It will have your lower back pain free in no time. I recommend doing these exercises daily until lower back pain is relieved. Have fun with your movements and continue to stay active.

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OUT OF THE OR EQ Factor

The Empathetic Trainer: Using EQ for Training Success By Daniel Bobinski ability to stand up and T he talk does not a trainer

make. I know that sounds like I’m quoting from Yoda in “The Empire Strikes Back,” but some of the most high-tech companies in the world deliver some of the worst training I’ve ever seen. One problem can be when a trainer’s desire to be seen as an expert supersedes a desire – and an ability – to help others learn. That’s because trainers need to show empathy, and empathy consists of caring about and striving to understand someone else’s point of view. Longtime readers of this column know that empathy is a key component in emotional intelligence (EQ). A number of years ago I was brought into a Fortune 50 company to help subject matter experts become better trainers. Not long after my arrival, I observed a trainer walking back in forth in front of his class for an hour, reciting stories and offering platitudes. As I looked around the room, it was obvious the learners were bored. My observations were affirmed when one of the company’s senior managers turned to me and said, “This is horrible. This is nothing but a ‘sage on the stage.’ Nobody is learning.” She was right. That’s because learning is the transfer of knowledge,

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skills and attitudes, and a fundamental starting point for trainers is caring about the students’ perspective. Why are they there? What do they hope to gain from attending the training? What needs to happen so the students in attendance feel like their time was invested wisely? Think about it. In the workplace, when adults are placed in learning situations, many feel vulnerable. This is especially true in professional fields, because when someone doesn’t possess a particular body of knowledge, that person can be perceived as “less than.” Therefore, it is incumbent upon the trainer to create what I call an emotionally safe atmosphere. Adults do not want to be talked down to nor made to feel inferior, especially without any hint of how to apply what’s being presented. This is why emotional intelligence is so important for trainers. Training involves watching for audience cues to track whether learners are connecting. Also, since learners often have questions, people with high EQ are better able to adapt and engage, answering in a way so as to establish positive relationships. The definition of EQ is a vital foundation: perceive and assess one’s own and other’s emotions, desires, and tendencies, then make decisions

which lead to the best result for all concerned. Training others goes way beyond talking. It means being quick to ascertain learners’ emotions, desires, and tendencies so that good decisions can be made in ways that facilitate a transfer of knowledge, skills and attitudes. Oftentimes a learner asks a question due to feeling insecure or doubtful about how to apply the material. How a trainer answers can make or break that learner’s confidence. Determining a learner’s motive for asking without embarrassing that learner shows strong emotional intelligence. Acting like the repository of all knowledge – being the sage on the stage – does not. Daniel Bobinski, who has a doctorate in theology, is a bestselling author and a popular speaker at conferences and retreats. For more than 30 years he’s been working with teams and individuals (1:1 coaching) to help them achieve excellence. He was also teaching Emotional Intelligence since before it was a thing. Reach him by email at DanielBobinski@ protonmail.com or 208-375-7606.

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12/1/23 9:40 AM

OUT OF THE OR nutrition

The Top 10 AntiInflammatory Foods By Grace O nflammation is a natural I response of the body in

times of illness or stress but, if left unchecked, this response can cause chronic health problems. Chronically elevated inflammation is associated with cardiovascular disease, Alzheimer’s and other cognitive issues, type 2 diabetes, autoimmune diseases and even some cancers. Here are 10 anti-inflammatory foods to include in your diet. 1. Apples: Apples are nutrientrich and are great for your heart. The fiber in apples contains pectin, which can contribute to decreased blood cholesterol levels. 2. Beans: Packed with fiber and protein, beans have been shown in studies to reduce the risk of cardiovascular disease and type 2 diabetes.

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3. Berries: Choose strawberries, blueberries, blackberries, raspberries, or a more exotic variety like açai, because all these brightly colored berries are anti-inflammatory powerhouses. 4. Broccoli: Cruciferous veggies like broccoli, cauliflower, kale, Brussels sprouts and cabbage are powerful both for supporting detoxification and calming chronic inflammation. 5. Chia seeds : Chia seeds offer a huge nutritional benefit. They’re rich in fiber; minerals like iron, and omega-3s to reduce chronic inflammation; and they promote healthy digestion and elimination. 6. Fish: Cold-water fatty fish like salmon, halibut, sardines, mackerel, herring, anchovies and trout are rich in protein, vitamins, minerals and antiinflammatory omega-3 fats.

7. Green Tea: The most antiinflammatory compound in green tea is a special antioxidant called EGCG. Tea is hydrating, which also supports the body and calms inflammation. 8. Spinach: Adding spinach or other dark leafy greens to your daily diet can maximize benefits like decreased inflammation and reduced risk for certain cancers and cardiovascular disease. 9. Tomatoes: Famous for their lycopene, tomatoes have been shown to protect against certain cancers (especially prostate) and support heart health as well. 10. Walnuts: Higher in antiinflammatory omega-3 fatty acids than other nuts like almonds, pistachios, or cashews, walnuts are a perfect snack.

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OUT OF THE OR

nutrition

thai Shrimp and Pineapple Curry In my new cookbook, “Anti-Aging Dishes from Around the World,” you’ll find my recipe for Thai Shrimp and Pineapple Curry which delivers loads of anti-inflammatory benefits. This curry is delicious over white or black rice. I use monk fruit sweetener to reduce the impact cane or beet sugar can have on your blood glucose levels. Monk fruit also has no calories, and it’s completely natural. You can use coconut sugar instead, but like cane sugar, it will impact your blood sugar and is caloric. Benefits: Pineapple contains bromelain, an enzyme that aids digestion by breaking down proteins. Coconut milk contains some medium-chain triglycerides (MCTs) which are broken down more easily by the body, as well as the anti-inflammatory, antimicrobial, antibacterial and antiviral lauric acid. This dish can be gluten-free if using tamari.

Procedure 1.

Make the curry sauce: In a medium saucepan, heat 1 Tbs. oil over medium-high heat. Add the butter and curry powder and cook, stirring constantly, for 1 minute or until fragrant. Add the coconut milk and sweetener and bring to a boil. Reduce to low heat and simmer, uncovered, for about 5 minutes or until the sauce is slightly thickened. Remove from the heat and stir in the lime juice, zest, and soy or tamari sauce. Set aside. In a large skillet, heat 1 Tbs. oil over high heat. Add the shrimp and cook, 4 to 5 minutes, or until opaque. Remove to a plate. Add the remaining oil to the skillet, then the

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onion and bell pepper. Cook, stirring often, for 2to 3-minutes or until the vegetables are tender. Add the curry sauce, shrimp, pineapple, and ¼ cup cilantro leaves and cook for about 1 minute or until the sauce is thickened. Spoon about 1 cup of rice into each bowl. Divide the shrimp mixture evenly among the four bowls and top with the remaining cilantro, scallions and peanuts (if using).

– Grace O is the creator of FoodTrients, a unique program for optimizing wellness and longevity. She is the author of three award-winning cookbooks. Her latest cookbook is “Anti-Aging Dishes from Around the World.” Learn more at FoodTrients.com/recipes/anti-inflammatory.

Ingredients Serves 4 • 3 Tbs. coconut oil, divided • 1 Tbs. butter • 2 tsp. curry powder • 1 can (13.5 oz.) light coconut milk, well shaken • 2 Tbs. monk fruit sweetener (or coconut sugar) • 2 Tbs. fresh lime juice • 1 tsp. lime zest • 1 Tbs. soy sauce or tamari • 1¼ lbs. medium-size shrimp, peeled and deveined • 1½ cups chopped white onion • 1¼ cups chopped red bell pepper • 2 cups of pineapple chunks • ½ cup chopped fresh cilantro leaves, divided • 4 cups cooked white or black rice • 3 Tbs. thinly sliced scallions • 1 Tbs. chopped fresh mint leaves (optional) • 3 Tbs. chopped unsalted peanuts (optional)

Winter 2024 | OR TODAY

12/1/23 9:40 AM

OUT OF THE OR recipe

Tex-Mex Sweet potato Beef Skillet INGREDIENTS: • 2 medium sweetpotatoes

Recipe

• 3 bell peppers (combination of red, yellow and orange)

the

• 1 small onion • 2 tablespoons olive oil or butter, divided • 2 garlic cloves, minced • 1 pound lean ground beef • 1/2 cup beef broth • 1 can diced tomatoes • 8 ounces tomato sauce • 1 can Mexi-corn or Southwest corn • 1 tablespoon Southwest seasoning salt, to taste pepper, to taste

By family features

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Fill Up with a Tex-Mex Skillet or busy families, it’s hard to beat a

F one-skillet dish that cuts down on

cleanup without sacrificing flavor. Especially when cool, crisp days call for comforting food, you can warm up the evening with a hot Tex-Mex meal that’s sure to occupy a permanent spot on the menu. Start with a versatile comfort food staple like sweetpotatoes, which provide the body for this filling Tex-Mex Sweetpotato Beef Skillet. As a versatile veggie that’s easy to add to a variety of recipes for enhanced flavor and nutrition content, they can become a pantry must in your home for simple and elevated recipes alike. To maximize their already-lengthy shelf life (up to 4 weeks), simply store in a cool, dry, well-ventilated area away from

OUT OF THE OR recipe

heat sources – never in the refrigerator, which can cause “chill damage.” Because they can be cooked and prepared in a skillet, baked, grilled, slow-cooked, microwaved, airfried and more, they provide a crowd favorite that’s a breeze to use in the kitchen. In this delicious dish, they’re combined with peppers, onions, ground beef, broth, tomatoes, corn, Southwest seasoning and more to keep chilly days at bay. Consider this fun fact to share with your loved ones at the dinner table: The one-word spelling of “sweetpotato” was officially adopted by the National Sweetpotato Collaborators in 1989 to avoid confusion with equally unique and distinctive potatoes, which are also grown and marketed commercially in the United States. Find more comfort food favorites by visiting ncsweetpotatoes.com.

Tex-Mex Sweet potato Beef Skillet Servings: 6

1. Rinse and scrub sweetpotatoes to clean. Chop into 1/2-inch cubes. Dice bell pepper and onion. Set aside. 2. In skillet over medium heat, heat 1 tablespoon oil or butter. 3. Add garlic and saute until fragrant, being careful not to burn. 4. Add ground beef, breaking apart and stirring until cooked through, 5-7 minutes. Remove garlic and beef to covered bowl or plate; set aside. 5. In same skillet, add remaining oil or butter. Saute peppers, onion and sweetpotatoes until slightly tender. 6. Pour in broth, diced tomatoes and tomato sauce; cover and simmer 1215 minutes. 7. Stir in cooked beef and corn. Cook until liquid reduces and mixture thickens slightly. Add seasoning and salt and pepper, to taste.

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INDEX

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ALPHABETICAL AIV Inc.………………………………………………………………… 4

Innovative Medical Products………………………… 39

MD Technologies Inc.……………………………………… 23

AORN…………………………………………………………………… 9

Innovatus Imaging……………………………………………… 5

Milestone Medical……………………………………… 30, 31

C Change Surgical………………………………………………21

International X-Ray Brokers…………………………… 29

OR Today Webinar Series…………………………………19

CIVCO Medical Solutions…………………………………15

Jet Medical Electronics Inc…………………………… 47

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

Cygnus Medical………………………………………………… BC

Kapp Surgical Instrument Inc………………………… 47

SIPS Consults………………………………………………………17

Healthmark Industries Company, Inc.…………… 6

MAC Medical, Inc………………………………………… 27, 55

USOC Medical…………………………………………………… 10

ASSOCIATION

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

REPROCESSING STATIONS

AORN…………………………………………………………………… 9

SIPS Consults………………………………………………………17

CIVCO Medical Solutions…………………………………15

CARDIAC PRODUCTS

INSTRUMENT STORAGE/TRANSPORT

MD Technologies Inc.……………………………………… 23

C Change Surgical………………………………………………21

CIVCO Medical Solutions…………………………………15

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

CIVCO Medical Solutions…………………………………15

Cygnus Medical………………………………………………… BC

SAFETY

Jet Medical Electronics Inc…………………………… 47

Milestone Medical……………………………………… 30, 31

Healthmark Industries Company, Inc.…………… 6

Kapp Surgical Instrument Inc………………………… 47

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

Milestone Medical……………………………………… 30, 31

CARTS/CABINETS

MAMMOGRAPHY

SINKS

CIVCO Medical Solutions…………………………………15

International X-Ray Brokers…………………………… 29

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

Cygnus Medical………………………………………………… BC

MEDICAL IMAGING TABLES

STERILIZATION

International X-Ray Brokers…………………………… 29

Cygnus Medical………………………………………………… BC

MONITORS

Healthmark Industries Company, Inc.…………… 6

CATEGORICAL

Healthmark Industries Company, Inc.…………… 6 MAC Medical, Inc………………………………………… 27, 55

CS/SPD CIVCO Medical Solutions…………………………………15 MD Technologies Inc.……………………………………… 23 Ruhof Corporation…………………………………………… 2,3

DISINFECTION CIVCO Medical Solutions…………………………………15

USOC Medical…………………………………………………… 10

MD Technologies Inc.……………………………………… 23

MRI

SURGICAL

Innovatus Imaging……………………………………………… 5

ONLINE RESOURCE OR Today Webinar Series…………………………………19

MD Technologies Inc.……………………………………… 23 Milestone Medical……………………………………… 30, 31 SIPS Consults………………………………………………………17

SURGICAL INSTRUMENT/ACCESSORIES

Cygnus Medical………………………………………………… BC

OR TABLES

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

International X-Ray Brokers…………………………… 29

DISPOSABLES

OR TABLES/BOOMS/ACCESSORIES

Healthmark Industries Company, Inc.…………… 6

CIVCO Medical Solutions…………………………………15

Innovative Medical Products………………………… 39

Kapp Surgical Instrument Inc………………………… 47

ENDOSCOPY

OTHER

TELEMETRY

CIVCO Medical Solutions…………………………………15

AIV Inc.………………………………………………………………… 4

Cygnus Medical………………………………………………… BC

PATIENT DATA MANAGEMENT

USOC Medical…………………………………………………… 10

Healthmark Industries Company, Inc.…………… 6 MD Technologies Inc.……………………………………… 23 Ruhof Corporation…………………………………………… 2,3

FLUID MANAGEMENT MD Technologies Inc.……………………………………… 23

GENERAL AIV Inc.………………………………………………………………… 4 Milestone Medical……………………………………… 30, 31

INFECTION CONTROL CIVCO Medical Solutions…………………………………15 Cygnus Medical………………………………………………… BC Healthmark Industries Company, Inc.…………… 6 MD Technologies Inc.……………………………………… 23

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C Change Surgical………………………………………………21 Cygnus Medical………………………………………………… BC

MAC Medical, Inc………………………………………… 27, 55

TEMPERATURE MANAGEMENT

PATIENT MONITORING

C Change Surgical………………………………………………21

AIV Inc.………………………………………………………………… 4

MAC Medical, Inc………………………………………… 27, 55

Jet Medical Electronics Inc…………………………… 47

ULTRASOUND

USOC Medical…………………………………………………… 10

Innovatus Imaging……………………………………………… 5

POSITIONING PRODUCTS

WARMERS

Cygnus Medical………………………………………………… BC

MAC Medical, Inc………………………………………… 27, 55

Innovative Medical Products………………………… 39

WASTE MANAGEMENT

Kapp Surgical Instrument Inc………………………… 47

REPAIR SERVICES Cygnus Medical………………………………………………… BC Jet Medical Electronics Inc…………………………… 47

MD Technologies Inc.……………………………………… 23

X-RAY Innovatus Imaging……………………………………………… 5 International X-Ray Brokers…………………………… 29

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