OR Connection Volume 8 Issue 2 by Medline Industries

The Aligning practice with policy to improve

patient care

Volume 8, Issue 2, August 2013

Special Social Media Issue! The Facts on VentilatorAssociated Events Creating a Quieter Hospital Stay Breast Cancer Awareness Spreads Worldwide

Congratula tions!

Pink Glove D ance Photo W inners El Centro Reg ional Medica l Center

Free CE PAGE 38!

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Cover

This fun bunch of perioperative nurses from El Centro Regional Medical Center in El Centro, Calif. won Medline’s Pink Glove Photo Contest at the 2013 AORN Congress in March. Left to right: Maria Tomacruz, RN; Oscar Chavez, RN, BSN, OR Director; Jayme Storms, RN, BSN and Luana Self, RN, BSN.

The OR Connection I www.medline.com I August 2013

C O N T E N T S A UG US T 2013

F E AT U R E S

Editor Sue MacInnes, RD Senior Writer Carla Esser Lake

Creative Director Michael A. Gotti Clinical Team

Patientsâ&#x20AC;&#x2122; Most Frequent Complaint: Noise. Facing potential financial penalties from the Centers for Medicare and Medicaid Services (CMS), hospitals are making changes to lower the noise level for patients.

Getting Started with Social Media in Health Care. Learn how and why to get connected to Twitter, Facebook and other forms of social media.

Jayne Barkman, BSN, RN, CNOR Lorri Downs, BSN, MS, RN, CIC Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA Joan Ferrara, BA, RN, CNOR Kimberly Haines, RN, Certified OR Nurse Rebecca Huff, MSN, RN Angel Trichak, BSN, RN, CNOR

About Medline Medline, headquartered in Mundelein, IL, manufactures and distributes more than 350,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 1,100 dedicated sales representatives nationwide to support its broad product line and cost management services. ÂŠ2013 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

CE ARTICLE

Understanding VentilatorAssociated Events. Find out why the Centers for Disease Control and Prevention changed its focus on mainly ventilator-associated pneumonia to all ventilator complications in general and what this means for your clinical practice.

The New Medline.com. Better products. Better outcomes. Better website. Visit today to test drive all the new features.

August 2013 I www.medline.com I The OR Connection

Letter from the e d it or

Change… Change… Change… Do you embrace it or resist it? I say embrace it. You can either be the champion and lead or be the naysayer and be left in the dust. Last spring, shortly after AORN Congress in San Diego, I went to a meeting called the CMO Collective. Chief marketing officers from Unilever, Jockey, General Mills, Valspar, Accenture and even the CMO of the Cleveland Clinic attended. The big buzz was “social”… how social media was the future. One breakout session was about content marketing. The executive vice president of Unilever discussed a newly released YouTube video promoting Dove soap called “Real Beauty Sketches.” In the video, a forensic artist sketches pictures of women without actually seeing them. He only goes by how they describe themselves. The artist then sketches the women a second time according to how someone else describes them. The second set of sketches is more accurate and the women look more beautiful. Interestingly, the women are overly critical when they describe themselves – to the point of being inaccurate. If you haven’t seen the video you may want to check it out at www. youtube.com/watch?v=XpaOjMXyJGk. It was released April 14 and had more than 48 million views in less than a month. At the meeting, Accenture reported that 80 percent of people in the United States are using some type of mobile device. Also, there are four million tweets a day (Twitter has been around for only seven years), three million emails a day and 20 hours of YouTube video produced every hour. The discussion centered on how our society is totally transparent AND all organizations have become public in the online community. We heard analogies about how Amazon has replaced Barnes and Noble … Netflix has replaced Blockbuster … I think you get it.

Our world as we have known it is changing and “social” is the future of communication. Our patients and families are more active than ever and looking to communicate. I know for myself and for Medline we have to embrace this change and do great things to communicate, provide information, train and educate. The possibilities in this new “age” of ours are endless, but we need to embrace them. So, why am I talking about this? Medline wants to connect with you on Twitter, Facebook, LinkedIn, Pinterest, Google+, Medline University … there are countless ways to connect and provide real-time information. I feel soooo passionate about this that we’ve included an article called “Getting Started with Social Media in Health Care” (page 16) to give you the how tos so you can learn to embrace this change. Let’s be social media friends! I have to tell you … at least for me, I kind of feel younger and more hip now that I know how to navigate social media. Throughout The OR Connection we have referenced ways that you can connect with Medline! Along with our desire to provide you with really good information via social networking, Medline also recently released the NEW Medline.com. (See story page 46.) So, what changed and how can this become a better resource for you? 1. The site was designed by awardwinning designer Deborah Adler, who designed our new EMPOWER Surgical Trays (see back cover) packaging as well as Target’s prescription drug bottles called the ClearRx System. 2. The architecture and functionality was completed by one of the most renowned web design companies in the country.

The OR Connection I www.medline.com I August 2013

3. The content has been rewritten, upgraded and expanded from 80 pages to more than 400. 4. Once users select their area in health care they will automatically see information customized to their specialty every time they return to medline.com. 5. There are videos, white papers, research … you name it. The site is rich with content. 6. The “About Us” section has great information about the company, our history, leadership and career opportunities. 7. There is now a blog that will be updated multiple times a day with messages from leadership, interesting PR, new launches … fun stuff!! 8. The site works well on mobile devices as well as desktop computers. REMEMBER• All previous articles from both The OR Connection and Healthy Skin can be accessed on Medline University.com. • You can communicate with us directly though Facebook, Twitter, LinkedIn, Google+ and YouTube, to name a few. Look at pages 16-22 and check out all the cool things that have been developed to connect us better. Medline has truly joined the digital age of communication. This is just the beginning. Take a look! Best Regards and follow me on Twitter,

Sue MacInnes, RD Editor Follow on Twitter: @smacinne Connect on LinkedIn: LinkedIn.com/in/smacinnes

Join 400,000 other nurses for FREE CE courses

At the all-new Medline University w 220 courses w 20 curriculum tracks w Interactive competencies w Flexible access: PC, iPhone, iPad w Free registration

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/ MedlineU ÂŠ2013 Medline Industries, Inc. Medline and Medline University are registered trademarks of Medline Industries, Inc.

CONT E NT S AU G US T 2 0 1 3

I n T h i s Issue

7 OR News

24 Sterile Processing Corner Benchmarking in Variable Circumstances 31 Lean How to Rapidly Improve OR Efficiency 50 Caring for Yourself The Science Behind a Positive Attitude

50 58

55 Just for Fun OR Nurse Emma Models Medline AVE. Scrubs 58 64

Breast Cancer Awareness Early Detection Medline and the National Breast Cancer Foundation

66 Recipe Lemon Bread Forms & Tools 69 VAP FAQs – English 72 VAP FAQs – Español 75 VAE Data Collection

Connect with us: /MedlineIndustriesInc

/medline /medline /medlineindustries /medline /medline.com/blog /medlineindustriesinc /+medline

The OR Connection I www.medline.com I August 2013

OR N EWS

HIGHER RISK FOR ERROR IN NOISY ORs1

CHALK ANOTHER ONE UP FOR THE POWER OF SURGICAL CHECKLISTS3

A recent study published in the Journal of the American College of Surgeons concluded that noise in the operating room (OR) directly affects a surgeon’s ability to understand spoken words, which can result in errors. The study tested 15 surgeons with one to 30 years of operating experience under four typical listening conditions in the OR: quiet, filtered noise through a surgical mask, background noise with music and background noise without music. Surgeons’ speech comprehension diminished in the presence of music compared with a quiet environment or typical OR background noise. According to the researchers, surgical teams may need to turn down the music and limit background conversations to create the safest environment possible.

A total of 17 operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a study during 106 simulated surgical crises scenarios either with access to a crisis management checklist or on the basis of memory alone. Failure to adhere to the lifesaving steps during crisis management occurred significantly more often in the absence of the crisis checklist than with access to it (23% of steps missed versus 6%, respectively). In addition, 97 percent of participating clinicians agreed that they would want such a checklist to be used if they had an interoperative crisis as a patient. This study adds further weight to the importance of checklists during critical periods of patient care.

HOSPITAL LAUNDERING FAILS TO REMOVE BACTERIA FROM CLEANING TOWELS2 Freshly laundered towels intended for cleaning purposes were collected from 10 major hospitals in Arizona. Results showed 93 percent of the towels contained viable bacteria, including: • Spore-forming bacteria (56 percent) • Coliform bacteria (23 percent) • Escherichia coli (3.3 percent) Molds were also found in 13 percent of laundered towels.

References 1. W ay TJ, Long A, Weihing J, et al. Effect of noise on auditory processing in the operating room. J Am Coll Surg. 2013; 216(5):933-938. 2. H ospital laundering practices may contribute to HAIS. OR Manager. 2013; 29(7):15. 3. A rriaga AF, Bader AM, Wong JM, et al. Simulation-based trial of surgical-crisis checklists. The New England Journal of Medicine. 2013; 368(3):246-253

Another study conducted by the same researchers also found that laundered cotton towels reduced the strength of hospitalgrade disinfectants by 85.3 percent, which resulted in failure of the disinfectants in 96 percent of tests performed.

August 2013 I www.medline.com I The OR Connection

Contrib ut ing W r ite r s

Michelle DeMeo

Michele DeMeo is an expert in the sterile processing field who is highly regarded for her management techniques, product development and contributions to various healthcare associations and professional publications. She is now tackling another important role – learning to live well in the face of a terminal illness.

Lorri Downs, RN, BSN, MS, CIC

Lorri Downs is a board-certified infection preventionist. She has a diverse portfolio of more than 25 years in nursing. Her expertise focuses on infection prevention surveillance at large acute care organizations, plus ambulatory and public health settings. Lorri has developed hospital infection control programs and local emergency preparedness plans, and she lectures on various infection prevention topics.

Chad Plass

Social Media Manager at Medline Industries, Inc. Experienced social strategist with over 12 years experience developing both B2B and B2C digital and social marketing campaigns. He currently manages the social media accounts and presence for Medline, Medline University, Pink Glove Dance, and Medline Careers actively supporting Medline’s mission and vision through the social media. You can connect with him on LinkedIn: linkedin.com/in/cplass Dr. Wolf J. Rinke, RDN, CSP

President, Wolf Rinke Associates, Inc. CPE Accredited Provider of pre-approved high quality home study courses since 1990. Receive the FREE eNewsletter: “Read and Grow Rich” for savvy Nutrition Professionals who want to succeed faster. To subscribe go to www.easyCPEcredits.com and click on the newsletter link. 13621 Gilbride Lane, Clarksville, MD 21029, USA, Tel. 800-828-9653, 410-531-9280, fax 410-531-9282. Email:WolfRinke@aol.com; ORDER ON-LINE www.easyCPEcredits.com

The OR Connection I www.medline.com I August 2013

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10 The OR Connection I www.medline.com I August 2013

NOI S E Pat i ent S ati sfacti on

Hospitals Work on Patients’ Most-Frequent Complaint:

NOISE

By Laura Landro The Wall Street Journal June 10, 2013

First it’s the beeping of a heart monitor. A nurse comes in to take a patient’s temperature. There’s conversation during the shift change, overhead pagers, a visitor’s cellphone conversation and the din of a TV talk show. An aide pushes a cart of rattling dishes. An alarm goes off when IV medication is finished. All these sounds make up the steady assault of beeps and bustle during a typical night in a hospital bed. More hospitals are getting creative about lowering the noise level, masking intrusive sound and distracting patients from the cacophony. Facing potential financial penalties from Medicare, more hospitals are changing decades-old practices that contribute to the din. Some are replacing overhead staff paging systems with wireless headsets, and allowing patients to shut room doors and post a Do Not Disturb sign. Designated sleep hours in some units mean there are no routine checks of vital signs unless necessary. Some hospitals are installing ambient white-noise machines and soundabsorbing ceiling tiles and carpets in rooms and corridors. They are offering televisions with closed-circuit “relaxation programming” of soothing music and nature imagery. “Quiet Kits” with sleep masks, earplugs and crossword puzzles help patients tune out intrusive sound. Hospital noise is more than an annoyance. It disturbs patient sleep, prompts spikes in blood pressure and interferes with wound healing and pain management, studies show. Some hospitals have installed a device like a traffic light that heightens awareness of the need for quiet by monitoring the noise level and turning from yellow to red as it rises.

Noise-reduction efforts really gained momentum last year, when Medicare began basing a portion of hospital reimbursement on quality measurements including patient ratings of the quality of care. Noise consistently gets the worst marks on patient surveys. The latest data from the federal program for the year ended in June 2012 shows that only 60% of patients said the area outside their room was quiet at night, representing the lowest satisfaction score among 27 questions about the hospital experience. In a 2013 State of Patient Experience report released in April by the Beryl Institute, a nonprofit that helps hospitals improve patient satisfaction, hospital administrators ranked noise reduction as their top priority for the second time since the last report in 2011. They cited changing behavior and culture as the biggest challenge. “There is a constant tension in hospitals between the need to create

August 2013 I www.medline.com I The OR Connection

Pati ent Satisfact ion NOI SE

“Hospitals are asking staffers to use ‘library’ voices because quiet murmurs can be more comforting than normal speaking tones.” a place where patients can rest and heal and the realities of an active and almost chaotic work environment,” says Jason Wolf, Beryl president. Noise can never be completely eradicated, he adds, but “we can counteract it.” Many hospitals now have only private rooms, but noise remains hard to control in shared rooms. A complicating factor is hospitals’ increasing openness, including more liberal visiting hours and policies that permit cell phones and other devices. “It’s also the responsibility of patients and family members to remember this is a hospital,” Mr. Wolf says. “You aren’t hanging out at your friend’s apartment.” Dignity Health, based in San Francisco, is forming quiet teams at its 39 hospitals to identify ways to reduce noise. Some are reducing the frequency and intensity of medical alarms, dimming lights in the evening and replacing nurses’ pagers and walkie-talkies with mobile headsets. Patients are getting Quiet Kits, whitenoise machines and headsets for TVs and iPads, says Tracy Sklar, senior vice president of quality, adding patient

satisfaction scores on noise levels have improved.

years in additional Medicare payments.

Margaret Burleson-Turner, 80, was admitted to Dignity Health’s St. John’s Regional Medical Center in Oxnard, Calif., after a heart attack in April. She says she was kept awake by the constant “ding ding ding” of bells, alarms and phones on the telemetry floor where she was monitored. She was transferred to a rehabilitation unit with a noise-reduction program and noted how sounds were muted and voices hushed. She used a sleep mask and Do Not Disturb sign for naps, and worked on the crossword puzzle to tune out her surroundings. Overall, she says the experience was like “being wrapped in a warm little blanket.”

“We encourage clients to stop chasing silence and increase the ratio of good sounds to bad noises,” Mr. Madaras says. Complete silence can actually be worrisome and isolating. The sickest patients “want to get quality sleep but want to feel connected to their caregivers and know that they are not far away” in case of an emergency, he adds.

Some hospitals hire consultants offering “soundscaping” solutions, including architectural changes and the use of ambient sound. Gary Madaras, director of Making Hospitals Quiet, a consulting service, says a $10,000-to-$50,000 investment over two years can raise patient satisfaction scores enough to bring in $100,000 to $150,000 over three

12 The OR Connection I www.medline.com I August 2013

Hospitals are asking staffers to use “library” voices because quiet murmurs can be more comforting than normal speaking tones. They are adding white-noise machines in patient rooms and hallways because studies show sleep and relaxation are aided by an unvarying but unobtrusive sound. A recent study at Baylor Health Care System’s Heart Hospital in Plano, Texas, found white-noise machines made no difference in patient perception of noise

in rooms. But construction during the study period may have elevated noise levels, according to Linda Tjiong, a study investigator and director of education and research at Baylor Medical Center at McKinney. That facility, which opened last summer, is installing white-noise machines in some halls and common areas to mask noise. Terri Nuss, vice president of patient centeredness at Dallasbased Baylor, says there may be other factors to weigh against noise mitigation. Smooth, hard surfaces enhance noise but they are easy to clean and help fight infection. Alarms alert staff to potential emergencies. “We are trying to figure out what is an acceptable sound level,” she says. The CARE Channel—it stands for “continuous ambient relaxation environment”—offers a 24/7 television menu of original instrumental music and nature imagery, including a starry night sky. Susan Mazer, chief executive producer of Healing HealthCare Systems Inc., says foreground music can mask other sounds and has been shown to induce relaxation and improve the quality of sleep.

The Roar of the Hospital Some common sources of hospital noise and creative solutions: • Loudspeaker paging system: More staffers have wireless

headsets and vibrating pagers. • Televisions: Patients use headsets, and some hospitals offer closed-circuit programming of music and nature imagery. • Talking visitors: Where appropriate, patients can close room doors and post Do Not Disturb signs. • Medical equipment: White-noise machines can mask the sound; in some cases, lower-decibel alarms can be used. • Squeaky carts, clattering trays: Sound-absorbing ceiling tiles and carpets help reduce the din. • Caregiver conversation: Designated “sleep hours” mean there are no routine checks of vital signs unless medically necessary. Lights are dimmed in evenings to encourage quiet. • Patient noise: “Quiet Kits” with earplugs, sleep masks and puzzles help tune out staff and equipment noise or a chatty roommate with a cell phone.

August 2013 I www.medline.com I The OR Connection

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Custom-designed QuietPac Restful sleep is one of the most important elements of healing. Offer patients amenities that will help them feel calm and well-rested.

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Contact your Medline representative or call 1-800-MEDLINE to learn more about developing customized patient Care Pacs for your healthcare system.

Feature So cial Me d ia

by Chad Plass

todayâ&#x20AC;&#x2122;s digital world, social media is having a profound effect on the way information is being conveyed and shared within the healthcare industry. More and more breaking news, clinical studies and new industry reports are being shared and tweeted through social media. Clinical nursing professionals are signing up, creating accounts, sharing information and increasing their presence across social sites. If you havenâ&#x20AC;&#x2122;t already joined in the movement, now is the time for you to get involved. Turn the page for some simple tips on how to get started with social media and become a part of the social conversation.

16 The OR Connection I www.medline.com I August 2013

August 2013 I www.medline.com I The OR Connection

Feature So cial Me d ia

1 Create Your Social Persona If you’re not already using social media, get started by joining some of the more prominently used social sites such as Facebook, Twitter, Instagram, Google+ and LinkedIn. Signing up for these sites is quick, free and requires minimal information. One rule of thumb to remember when creating your account and building your profile is that honesty is the best and most respectable policy. The more real you are with your profile information, bio, etc. the more likely people, brands and organizations will want to follow you.

2 To Follow or Not to Follow After you have created your profile, you’ll want to decide who to follow. Think about your interests, websites you enjoy, writers you respect, thought leaders you admire, and seek out their social media accounts and profiles. Once you find those accounts, you can then follow and/or subscribe to their social media profile to receive their latest updates, tweets and posts. As you begin to follow more accounts, people and brands, you will eventually find more accounts of interest and slowly build up the number of sites adding information to your social feed.

3 Search and Research Each day, every minute, and every second, there are millions of messages

being sent out from various social media accounts. Those messages can range from breaking news from the @CDC regarding the latest information on influenza, to new blog posts from healthcare bloggers like @MarkGraban. You can search and research relevant information related to your interests by using hashtags. Hashtags are keywords that have the hash sign (#) in front of them.

Most original authors love when you share their content and may even show appreciation for your efforts by thanking you via social media in a tweet or message. Also, through sharing and retweeting, those who follow you will appreciate your sharing relevant and useful content they may find interesting as well.

5 Join the Conversation

For example, if you wanted to see what’s happening in healthcare news, you would search #Healthcare. This can be done across almost all social media sites, including Twitter, Facebook and Google+, just to name a few. You can also get more detailed results by using a more specific hashtag such as #InfectionPrevention, which will pull up all specific posts, articles and messages related to infection prevention. Social search is a wonderful tool that can help you find people, businesses, and organizations that fall into your specific interest group.

4 Share and Retweet One of the best ways to become more involved with social media is through sharing, retweeting and forwarding information. On Twitter, when you want to share a tweet that you found interesting, you retweet it, meaning you re-send that very same message. If you share a message on Facebook or on LinkedIn, you are sharing that post and update with all of those individuals that you are connected to.

18 The OR Connection I www.medline.com I August 2013

It’s important with social media not only to get active, but to be vocal. Consistency is the key to staying engaged. Check your social sites often to engage with other users, comment on interesting posts and share your thoughts on the latest news, updates or findings. The more engaged you are as a social media user, the more likely you are to attract and grow your following and increase your social influence. When attending healthcare-related events or tradeshows, find out the hashtag for the event and send out tweets, posts or photos using that hashtag. You’ll be amazed by the connections you will make! These five tips are just a starting point. Don’t be afraid to ask questions, do your own research, and read other people’s posts before diving into the deep-end of social media. Everything takes time, and social media is constantly changing with new updates, sites and rollouts every day. Start slow, build up momentum and confidence and find what interests you most. The social world is out there just waiting to hear what you have to say.

Connect with Medline!

Twitter

Facebook

Instagram

Twitter is a social network made up of 140-character messages called tweets. It’s a fast and easy way to discover the latest news related to topics you find interesting.

Facebook is the largest social network in the world made up of more than one billion people. It’s a place to share stories, receive news, and catch the latest from the friends, brands and businesses you care about most.

Instagram is the world’s largest social photo sharing site. Right now there are over 45 million photos being shared daily.

To get started, go to twitter.com/ signup and enter your name, email address, secure password, and choose a username. Your name is your personal identifier (a business name or real name) displayed on your profile page. It will be used to identify you to friends, brands, and business partners. Your username, also called your handle, will appear in your profile URL and will be unique to you. Add an interesting bio about yourself describing your interests, professional background, etc. Now you’re set to tell people to start following you on Twitter using your “@” symbol and your username, such as @Medline. Happy tweeting!

Follow Medline on Twitter: @Medline or twitter.com/Medline

If you don’t have a Facebook account, signing up for one is easy and only takes a few short steps. First enter your name, birthday, gender and email address into the form on www.facebook.com. Then pick a password. After you’ve completed the sign up process, fill out your About section with information that you’d like to share about yourself. Finally, take the time to create a custom Username which will allow you to easily promote your presence on Facebook with a short URL. This username can be used in your marketing communications, company website and business cards. Example: Facebook.com/ MedlineU.

In order to sign up for an Instagram account you’ll need to use their app on your iOS (e.g., iPhone) or Android device. Below are some quick steps on how to get started. Download the Instagram app in the App Store for your iPhone/ iPad, or in Google Play for an Android device. Once the app is installed, tap the Instagram icon to open it, and tap Register. Here you can create a username and password and fill out your profile information. Share your username with friends, family, and business associates, letting them know to start following you on Instagram using your “@” symbol and your username.

Follow Medline on Instagram: Instagram.com/ Medlineindustriesinc or @Medlineindustriesinc.

Join and “Like” Medline on Facebook: facebook.com/ MedlineIndustriesInc.

Continued on page 21

August 2013 I www.medline.com I The OR Connection

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Get Social with Your Favorite Organizations

American Hospital Association (AHA) American Nurses Association (ANA) American Nurses Credentialing Center (ANCC) Association for the Advancement of Medical Instrumentation (AAMI) Association of Nurse Executives (AONE) Association of periOperative Registered Nurses (AORN) Association for Professionals in Infection Control and Epidemiology (APIC) Association of Surgical Technologists (AST) Centers for Disease Control and Prevention (CDC) The Joint Commission Medline Industries, Inc. Occupational Safety and Health Administration (OSHA)

4 4 4 4 4 4 4

4 4

4 4 4 4 4 4

4 4

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

August 2013 I www.medline.com I The OR Connection

Social Media F EATUR E

Are you a social media pro? Take this quiz to find out! (Tip: Questions can have multiple answers.)

1. W hat’s the maximum number of

4. Which of the following organizations has

a. The Joint Commission b. American Nurses Credentialing Center (ANCC) c. Medline d. Association of periOperative Registered Nurses (AORN) W hich of the following electronic devices

characters you can use on Twitter?

a. 140 b. 18 c. 55 d. 125

2. On which social media site did Medline’s first Pink Glove Dance video make its debut?

a. Facebook b. Twitter c. YouTube d. Instagram

3. What symbol appears when something

the most “likes” on their Facebook page?

can you use to participate on Instagram?

a. digital camera b. smart phone c. tablet with camera d. all of the above

goes wrong with Twitter?

a. sad face b. pig c. whale d. peace sign

What your score says about you Number of questions you answered correctly: 5 – You are a social media guru. Share your knowledge with your friends and colleagues! 4 – Great! You have arrived in the social media world. 3 – You have considerable knowledge about social media. Stay curious and keep learning! 2 – You are getting there! Ask for tips from a social media savvy friend. 1 – When was the last time you were on the Internet? 0 – Have you been hiding under a rock?

Answers: 1 a, 2 c, 3 c, 4 d, 5 b & c

22 The OR Connection I www.medline.com I August 2013

MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING

Each package is a 2-Minute Course in Advanced Wound Care ™

Medline’s Educational Packaging offers all the information you need, step by step, short and sweet, to help the Medline dressing do its job of healing. In a study involving 139 nurses at eight different facilities, 88% who used a wound care product with an education guide attached were able to apply the dressing correctly. None of the nurses who received traditional dressing packaging were able to apply the dressing correctly.1

www.medline.com/ep

Reference 1. Kent DJ. Effects of a just-in-time education intervention placed on wound dressing packages. Journal of Wound, Ostomy and Continence Nursing. 2010; 37(6):609-614. ©2013 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Steri le Process in g C o r ne r Ben c hmar k i n g

Benchmarking in Variable Circumstances by Michele DeMeo

There are so many misperceptions of true “benchmarking”ruminating out there in OR/SPD world. Buy-in has been slow, especially because every department in the United States and abroad believes they are so unique they cannot possibly be compared against another and come out with reliable data. It is true that facilities and departments differ, but not to the extent to preclude them from participation in a system of benchmarking products or services. Sure, some are better than others, but overall, the real issue is poor coaching from the service and a lack of understanding of statistical work. The responsibility for a department, such as the operating room or sterile processing boils down to understanding the means and methods of how outcomes become results. Some tips to make “benchmarking” more meaningful in changing times: • Remember institutional norms change. So do yours. Good and reliable benchmarking systems account for this and have a means to “normalize” data for you and others. • Having your own system and comparing it to another peer department with a different system is not correct data collection. You may have an impressive-looking document, but its content might not be accurate and, therefore, you might lose your ability to demonstrate true needs compared to similar departments. You might also appear very efficient when really you are not, or vice versa. • Benchmarking is not meant to be punitive, if conducted well. It is a useful method of comparing apples to the right and same type of apples, not to highlight apples against oranges. • When consistent methods are used, variable circumstances are not an issue. That is because the tools are built around these new norms or separate anomalies, giving you a chance to investigate your operational processes. Changing how you gather information simply to highlight your cause or rationalize your needs will result in more harm than good. You want what is best for your department, so putting effort into selecting the best tool is the best start. Stick with it, even if the results are less than what you anticipated. It is not much different from using Failure Modes Effects Analysis tools to pin point areas that are vulnerable for collapse or failure. Benchmarking in changing times actually can become a valuable friend when you need of proof of a cause or when you want to introduce a new project for your department.

24 The OR Connection I www.medline.com I August 2013

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Medline’s Lean consulting services for the OR help reduce waste and increase efficiency. During our clinical assessment, we focus on building the right surgical pack bundles that match their current procedural landscape. Identifying all routine supplies that are used from the beginning to the end of a procedure gives the surgical team the right supplies at the right time and eliminates supply waste.

• Streamlines routine supplies • Increases procedure coverage through data driven analysis • Maximizes your space For a no-obligation Lean assessment and analysis, contact your Medline representative or call 1-800-MEDLINE. #EmpowerOR

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What keeps YOU up at night? 26 The OR Connection I www.medline.com I August 2013

Medline is listening. EMPOWER is a comprehensive methodology to help healthcare leaders transform their OR through education, action, and outcomes.

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August 2013 I www.medline.com I The OR Connection

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O R E F F I C I E NCY LEAN

How to Rapidly Improve OR Efficiency by Ali Philander and Jacob Kupietzky

August 2013 I www.medline.com I The OR Connection

L EAN OR EFFIC I E N C Y

Hospitals can improve operating room (OR) efficiency — and contribution margins — in just 12 to 18 weeks using a rapid cycle change approach

Operating room (OR) efficiency is a measure of how well time and resources are deployed on a daily basis. When operating efficiently, the OR can bring in large profit margins. Some hospitals have seen contribution margins as high as $6,000 per surgeon, per OR hour (Dexter, F., and Ledolter, J., “Managing Risk and Expected Financial Return from Selective Expansion of Operating Room Capacity: Mean-Variance Analysis of a Hospital’s Portfolio of Surgeons,” Anesthesia & Analgesia, July 2003, pp. 190-195). On the other hand, a poorly run OR can be a huge financial weight on a hospital’s bottom line. Also, both physicians and patients find satisfaction in an OR environment where their cases are predictable and start on time, which ensures that the appropriate amount of time and resources match the expected schedule. While there are many different ways senior hospital leaders can implement change to improve OR efficiency, we recommend using the “rapid cycle change” approach. Rapid cycle change requires minimal time investment with a maximum impact and sustainable results. This approach almost always requires a dedicated team or task force to dig deep into problems within an organization and identify solutions to improve efficiency.

Case Example

Three Stages for Change

A 479-bed, for-profit hospital in the Southwest was experiencing poor efficiency and utilization, but did not understand the root causes, financial impact, and how to improve performance. After a thorough assessment was conducted, it was determined that there were significant opportunities to improve the following six areas:

There are three stages in a rapid cycle change engagement: assessment, redesign, and implementation. Each of these stages lasts up to four to six weeks and requires buy-in from senior hospital leadership and OR staff.

• First case start times • Case cancellation rates • Collaboration between preadmission testing (PAT), anesthesia, OR, and postanesthesia care unit staff • PAT processes • Turnover times • Preference card usage The OR team, along with its external support, used the rapid cycle change approach for more than eight weeks to redesign and improve the six areas by using flow charts, data, posters, and data transparency. There were also intensive workshops for OR and surgical staff members on such topics as leadership training, Lean management, teamwork, service training, and facilitation. Each area initiative had a leader and a physician co-sponsor who were responsible for tracking progress. In eight weeks, first case delays in the OR went from 23 minutes to nine, case cancellations dropped 16 percent, and utilization increased 33 percent. The hospital achieved $800,000 in cost savings and annualized new revenue of $550,000.

32 The OR Connection I www.medline.com I August 2013

Assessment. The first step is assembling a task force that will diagnose problems in OR operations, figure out why these problems exist, and communicate the problems to leadership and the OR staff. It is the responsibility of senior leadership, in collaboration with their physician partners, to structure a task force with mutual representation and responsibility for outcomes. This task force comprises physicians, nurses, and management who have OR experience and can objectively identify problems in OR operations. Secondly, these individuals should inspire the OR staff to change their current operating behaviors.

Once the OR task force is assembled, it should meet with OR staff, physicians, and members of senior leadership to communicate the following: • Why change is needed (for example, cost savings, patient and physician satisfaction) • Why staff should support the change initiative • How staff will have a critical role in shaping the changes • Whether rewards will be given for improvements • How the changes are in line with the hospital’s mission

This first meeting is meant to rally the physicians and staff behind the project and excite them about the pending changes. After this initial meeting, the task force should begin observing OR operations to identify where the inefficiencies are.

Focal Points for OR Assessment The following are key observation points when conducting an operating room (OR) assessment: Staffing

• OR overutilized (staff working overtime during cases scheduled outside of their scheduled hours) • OR underutilized (staff being paid when the OR is not in use) Delays

• Preoperative delays w Late start times: – Patient, surgeon, and/or anesthetist is late – Equipment failure – Understaffing (emergency situations) – Late equipment setup – Inadequate equipment available w Same-day cancellations – Patient cancels the day of surgery – Surgeon unavailability – Full ICU

Redesign. After the task force’s assessment findings have been presented, hospital leaders must determine which improvement opportunities the hospital should pursue. Typically, opportunities should yield a certain amount of financial and quality improvement in a defined period of time to justify the time and resource investment. The task force then works with hospital staff to redesign processes, eliminate bottlenecks, and improve efficiency of operations. Process redesign should be very organized and detailed. Project management documents should outline what responsibilities belong to each employee, the order of importance of process changes, and a timeline for when the changes will occur.

• Perioperative delays w Late getting into OR suite w While in OR suite: – Insufficient preoperative preparation – Communication failure – Contamination – Errors in job performance by physician, tech, nurse, or anesthetist – Malfunctioning or missing equipment – Turnover times (long turnover times are likely due to set up and clean up; however, there is a benefit to looking at turnover times by time of day, which can illustrate that the delay is not due to inefficient operating staff, but inefficient scheduling of cases, equipment available, or staffing) • Postoperative delays w Delay on postanesthesia care unit admission w Other issues that delay patient leaving the OR, such as pain management and appropriate bed availability

August 2013 I www.medline.com I The OR Connection

L EAN OR EFFIC IE N C Y

Key Elements of OR Redesign The following are common problems and solutions to improve OR efficiency processes: Staffing

• If your OR exceeds benchmark staffing ratios for OR techs, nurses, and other specialty personnel, explore whether this is appropriate given your patient population and what the additional staffing costs are. • Staffing must match the workload. This will save time in both overutilized and underutilized hours. If staffing does not match the workload, it may lead to negative contribution margins, decreasing physician and staff satisfaction, and longer lengths of stay. Delays

• Consider a daily huddle with the surgical team to talk about surgeries on the schedule for that day. This meeting ensures that errors in communication, preoperative prep, equipment cleaning, and availability can be avoided. • Set reasonable and tangible goals for turnaround times and delays by specialty and by surgeon. • Improve process flow by designating responsibilities to specific employees. w RN/extra tech: Pick up trash and any other items. Keep room as clean as possible during case. Disconnect cords and suctions as appropriate. Put solidifier in suction canisters. w RN: Call reports and make sure all paperwork is done as much as possible. w RN/float/extra tech: Ensure extra equipment is in the room for the next case or just outside the room to be moved in. • Create a system of disciplinary action. w Set up a mandatory meeting with the OR director when surgeons miss their start. • Call patients a day prior to their scheduled surgeries to discuss preoperative instructions, answer questions, and avoid same-day cancellations. • Improve turnover times. w Standardize setup and cleanup protocols by specialty type and by case type. w Adjust cleaning staff load to focus on time of day when many cases are being performed. w Add one or more turnover teams. w Make sure sufficient equipment is on-site to perform without reprocessing (Dexter, F., “Economics of Reducing Turnover Times,” available at: www.franklindexter.net/Lectures/TurnoverTime.pdf). • Use historical data to improve scheduling. Examine the average time it takes each surgeon to perform different types of surgeries, and schedule accordingly so resources are not wasted on overutilized or underutilized ORs.

Task force members and clinical directors work together to agree on short- and long-term goals that measure improvements, as well as efficiency metrics that allow performance tracking. For example, a hospital OR may set the goal of improving OR turnaround time to less than 25 minutes by March 2014. The turnaround time metric might be defined as the “mean time from the previous patient out of the OR to the next patient in the OR, including set up and clean up.”

This first meeting is meant to rally the physicians and staff behind the project and excite them about the pending changes. Implementation. The implementa-

tion portion of the initiative is crucial. The OR task force must educate and retrain staff, as well as help sustain results. Educational sessions should explain how processes and clinical protocols will change and give staff an opportunity to ask questions and voice concerns. New protocols and processes should be made available in written form for staff to keep and review. It is important to monitor the effectiveness of educational initiatives and compliance with protocols. Some hospitals have the capability to monitor compliance electronically. Hospitals that don’t have that capability should monitor compliance through shadowing and audits. Continued on page 36

34 The OR Connection I www.medline.com I August 2013

Sterillium Rub: Faster Rub to Glove No More Sticky Hands

Sterillium Rub Waterless Surgical Scrub evaporates quickly for faster OR preparation. Emollients leave hands feeling soft and silky — never sticky or tacky — minimizing friction and skin trauma when donning gloves. It’s also CHG, latex and non-latex compatible. Exceeds FDA Requirements1

Sterillium Rub is the only waterless, brushless surgical scrub with 80% (w/w) ethyl alcohol — the highest alcohol concentration of any surgical rub available in the US. Its long-lasting, persistent effect exceeds FDA requirements for surgical hand antisepsis. Sterillium Rub provides a rapid and comprehensive kill of transient and resident skin flora, with a 6 log reduction within two minutes.2

For more information on Sterillium Rub, contact your Medline representative, visit www.medline.com or call 1-800-MEDLINE.

#Sterillium @2013 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Sterillium is a registered trademark of Bode Chemie GmbH

L EAN OR EFFIC I E N C Y

Monitoring changes on a dashboard is imperative. This dashboard would help staff track whether they have met poor, medium, or high performance targets for each goal. For example, here are possible targets for the OR turnover time goal.

Measurements

Poor Performance

Medium Performance

High Performance

Turnover time (for all cases; mean time from previous patient out of the OR to next patient in the OR,

>40 minutes

25-40 minutes

<25 minutes

including set up and clean up)

This information should be shared on a weekly or monthly basis. For turnaround times and delays, it can be very effective to post this information by shift, department, and surgeon on a daily basis. Creating healthy competition can motivate your staff to perform. When goals are met, reward your team with a pizza lunch or something to acknowledge the team’s efforts and success. Daily encouragement and positive reinforcement is a must. An OR Committee

Once the initiative is underway, it is important to have adequate resources to monitor and sustain the success of the changes made in the OR. The best way to do this is through the creation of an OR committee, under the sponsorship of the hospital’s senior leadership team. An OR committee typically comprises administrative and physician staff and is charged with overseeing OR operations. Physicians on the committee should be well respected and well liked, and they should have the ability to steer their peers.

An OR committee has several main functions: • Coordinate and streamline preoperative, perioperative, and postoperative care • Monitor quality outcomes, patient satisfaction, and efficiency of care on a daily, weekly, and monthly basis • Understand current legal and regulatory standards • Use evidence-based medicine to make recommendations about clinical practices in the OR The committee would also monitor OR efficiency on a long-term basis, assuming the day-to-day oversight of the task force is no longer needed. Key Takeaways

The benefit of rapid cycle is that it accomplishes a lot in a short period of time. Hospitals should implement the essential pieces of this approachassessment, redesign, and implementation-when attempting to significantly change operations in a department.

We believe that any hospital can engage in a change initiative; the most difficult part is sustaining those changes. Without sustainability, all efforts are for naught. The following are essential key takeaways to reform OR operations and sustain those changes: • Assemble the right team — a team with experience and influence over OR staff • Involve OR staff: Engage and involve staff, physicians, and senior leadership throughout the process, and incorporate their feedback to ensure they feel listened to • Measure success with a dashboard and be transparent about performance-by specialty and staff member • Reward success: Remember and recognize your staff for doing a good job • Invigorate staff by reminding them what their efforts do for the hospital, for patient safety, and for satisfaction

Reprinted with permission from hfm magazine, April 2011; copyright the Healthcare Financial Management Association. Ali Philander is a senior analyst, HealthCare Transformation, LLC. Jacob Kupietzky is president, HealthCare Transformation, LLC.

36 The OR Connection I www.medline.com I August 2013

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38 The OR Connection I www.medline.com I August 2013

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Understanding Ventilator-Associated Events What is the deal with all the new acronyms? by Lorri A. Downs MS, BSN, RN, CIC

VAP, VAE, VAC, IVAC … Today’s medical care often comes with a plethora of acronyms and buzz words, which can make everything downright confusing. Let’s look at ventilatorassociated complications, for example. Quality initiatives in healthcare that target healthcare-associated infections all presume that experts can accurately identify and track healthcare- associated infections. “The reality of VAP [ventilator-associated pneumonia] surveillance is that it is time-consuming, subjective, inaccurate and inconsistently predicts outcomes.”1 When we focus on ventilator-associated infections, specifically VAP, experts acknowledge that it is a difficult diagnosis to make.

August 2013 I www.medline.com I The OR Connection

Venti lato r-A ss oc iated E ven ts C E ART I C L E The problem with focusing only on ventilatorassociated pneumonia Critical care and infectious disease clinicians agree that many complications that occur in a critical care patient present with subjective clinical signs can mimic ventilatorassociated pneumonia. For example: • Radiographic opacities: when the radiologist reviews a chest X-ray and completes the report you often will find phrases such as, “Opacities noted with a possible slight increase from yesterday, but may be due to the patient’s position. Opacities could represent atelectasis, pneumonia, or effusion.” As you can see, the radiology report is not specific and subject to interobserver variability. When you include additional clinical findings such as fever, abnormal white blood cell count, impaired oxygenation and increased secretions, the clinical picture could be related to any of the following complications: • ARDS • Infarction • Hemorrhage

Potential Diagnosis = • Tracheobronchitis • CLABSI • UTI • Drug Fever

• Fibrosis • Carcinoma • Lymphoma

Potential Diagnosis = • Pulmonary Edema • Atelectasis • Fibrosis

In addition to the subjective nature of radiographic and clinical signs and symptoms, microbiological evidence collection practices vary among providers, the testing can lack sensitivity and specificity, and to compound the issue, there is controversy in the medical community about what “best practice” should include. With all the surveillance difficulties surrounding VAP, something needed to change. In the fall of 2011, a multidisciplinary work group of clinical experts convened with the Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality Promotion (DHQP). The goal was to develop an alternative approach to surveillance for VAP. Focusing only on adults age 18 years and older, research was conducted with three goals in mind: • streamlining the definition to reduce ambiguity • improving reproducibility • enabling electronic collection of all variables.2 With this in mind, the focus moved away from looking only at pneumonia to looking at all ventilator complications in general. The CDC work group decided to cast a larger net with a new definition for ventilator-related complications. The new emphasis is directed at the importance of preventing all complications of mechanical ventilation, not just pneumonia. This in turn develops a clear description of what reliably can be interpreted using the new surveillance definitions. Following is a summary of the final surveillance definitions and changes the CDC implemented in January 2013. (If you need detailed training and information on VAE surveillance,

40 The OR Connection I www.medline.com I August 2013

refer to the CDC website at www.cdc.gov/NHSN) VAE surveillance definition algorithmA new tiered approach (Please keep in mind these changes are only for surveillance and are not clinical definitions, meaning they are not intended for medical management of patients on the ventilator.) The new surveillance definition includes three new terms: VAE= Ventilator-associated Event VAC= Ventilator-associated Condition IVAC= Infection-related Ventilatorassociated Complication So what does all of this mean to patients and front line nurses? Clinically, the medical care and treatment of ventilated patients remains the same. The changes involve how infection prevention teams determine what is and is not a hospital-acquired infection versus a hospital-acquired complication related to the ventilator. Evidence-based bundles – The front line clinical solution The Institute for Healthcare Improvement (IHI) published a ventilator bundle in 2006 and updated it in 2010 and 2012. The prevention bundle is a set of strategies healthcare workers can implement at the point of care to help reduce the risk of patients developing a ventilator-associated event (VAE). The 2010 update placed oral care with a chlorhexidine (CHG) mouth rinse on the list of activities to help reduce the risk of developing a ventilator-associated event such as VAP.

Improving Surveillance for Ventilator-Associated Events in Adults Centers for Disease Control and Prevention (CDC)

Overview and Proposed New Definition Algorithm What is the National Healthcare Safety Network (NHSN)? • NHSN is the CDC’s healthcare-associated infections (HAI) surveillance system (www.cdc.gov/nhsn). NHSN uses standard methodology and definitions to collect data from U.S. healthcare facilities. More than 5000 healthcare facilities in all 50 states now participate in NHSN. Most participating facilities report data on deviceassociated HAIs, including ventilator-associated pneumonia (VAP). Many states require hospitals to report HAIs using NHSN. How is VAP surveillance currently conducted in NHSN? • NHSN’s current pneumonia (PNEU) definitions were last updated in 2002, and were designed to be used for surveillance of all healthcare-associated pneumonia events, including (but not limited to) VAP. • Three components make up the current PNEU definitions: an “X-Ray” component (required), a “Signs and Symptoms” component (required), and a “Laboratory” component (optional). • VAP is specifically defined as a PNEU event that occurs at the time a ventilator is in place, or within 48 hours after a ventilator has been in place. There is currently no required duration that the ventilator must be/have been in place for a PNEU to qualify as a VAP. Why is the CDC changing the way VAP surveillance is done in NHSN? • The current PNEU definitions are useful for internal quality improvement purposes, but are limited by their subjectivity and complexity. It is necessary to have objective, reliable surveillance definitions for use in public reporting and inter-facility comparisons of event rates and federal pay-for-reporting and -performance programs. What is the CDC’s process for improving NHSN VAP surveillance? • The CDC’s Division of Healthcare Quality Promotion (DHQP) is collaborating with the CDC Prevention Epicenters (http://www.cdc.gov/hai/epicenters), the Critical Care Societies Collaborative (CCSC, http://ccsconline.org), other professional societies and subject matter experts, and federal partners. • DHQP initiated a collaboration with the CCSC in September 2011, and convened a VAP Surveillance Definition Working Group, consisting of representatives from several organizations with expertise in critical care, infectious diseases, healthcare epidemiology and surveillance, and infection control. Organization American Association of Critical-Care Nurses American Association for Respiratory Care American College of Chest Physicians American Thoracic Society Association of Professionals in Infection Control and Epidemiology Council of State and Territorial Epidemiologists HICPAC Surveillance Working Group Infectious Diseases Society of America Society for Healthcare Epidemiology of America Society of Critical Care Medicine

•

Representative(s) Ms. Suzanne Burns and Ms. Beth Hammer Dr. Dean Hess Drs. Robert Balk and David Gutterman Drs. Nicholas Hill and Mitchell Levy Ms. Linda Greene Ms. Carole VanAntwerpen Dr. Daniel Diekema Dr. Edward Septimus Dr. Michael Klompas Drs. Clifford Deutschman, Marin Kollef, and Pamela Lipsett

The Working Group recognized that there is currently no gold standard, valid, reliable definition for VAP. Even the most widely-used VAP definitions are neither sensitive nor specific for VAP. Therefore, the Working Group decided to pursue a different approach—development of a surveillance definition algorithm for detection of ventilator-associated events (VAEs). This algorithm will detect a broad range of conditions or complications occurring in mechanically-ventilated adult patients. Because the reliability of HAI definitions has become particularly important in recent years, the Working Group focused on definition criteria that use objective, clinical data that are expected to be readily available across the spectrum of mechanically-ventilated patients, intensive care units and facilities—in other words, criteria that are less likely to be influenced by variability in resources, subjectivity, and clinical practices—and that are potentially amenable to electronic data capture. National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

August 2013 I www.medline.com I The OR Connection

Venti lato r-A ss oc iated E ven ts C E ART I C L E NHSN Surveillance for Ventilator-Associated Events in Adults

What progress has the Working Group made? • The Working Group has proposed a new surveillance definition algorithm to detect VAEs in adult patients. It is not designed for use in the clinical care of patients. The Working Group anticipates that the new definition algorithm will continue to be refined, based on the results of field experience and additional research. The definition algorithm refinement process is, and will continue to be iterative, and will require the ongoing engagement of the critical care, infection prevention, infectious diseases and healthcare epidemiology communities. What is the new, proposed NHSN surveillance definition algorithm? • The definition algorithm (presented on page 3) is only for use with the following patients: o Patients ≥ 18 years of age; o Patients who have been intubated and mechanically ventilated for at least 3 calendar days; and o Patients in acute and long-term acute care hospitals and inpatient rehabilitation facilities. • NOTE: Patients receiving rescue mechanical ventilation therapies (e.g., high-frequency ventilation, extracorporeal membrane oxygenation, or mechanical ventilation in the prone position) are excluded from surveillance using the new, proposed definition algorithm. How is the new surveillance definition algorithm different from the current PNEU definitions? • The new algorithm: 1) will detect ventilator-associated conditions and complications, including (but not necessarily limited to) VAP; 2) requires a minimum period of time on the ventilator; 3) focuses on readily-available, objective clinical data; and 4) does not include chest radiograph findings. Why are chest radiographs not included in the new surveillance definition algorithm? • Evidence suggests that chest radiograph findings do not accurately identify patients with VAP. Furthermore, the variability in radiograph ordering practices, technique, interpretation, and reporting make chest radiograph findings less well-suited for inclusion in an objective, reliable surveillance definition algorithm to be used for public reporting and inter-facility comparisons of event rates and pay-for-reporting and -performance programs. How will I find cases using the new algorithm? • CDC is working on operational guidance to help healthcare facility staff implement the new algorithm for electronic or manual event detection, once it is ready for deployment in NHSN. A possible method to make VAE surveillance more efficient is to organize data elements in a flow sheet at the patient’s bedside. In the example below, the shaded area highlights the period during which a possible VAP event is detected. VentDay 1 2 3 4 5 6 7 8

PEEPmin 10 5 5 8 8 7 5 5

FiO2min 60 40 40 60 50 40 40 40

Tmin 37.9 37.1 36.9 38.1 38.4 36.5 36.2 36.7

Tmax 38.1 37.5 37.6 39.2 38.9 37.8 37.0 37.3

WBCmin 12.1 11.8 12.1 14.5 12.6 11.1 11.5 8.3

WBCmax 14.2 11.8 12.1 16.8 15.9 13.6 13.0 8.3

Antimicrobials None None None PIPTAZ, VANC PIPTAZ, VANC PIPTAZ, VANC PIPTAZ, VANC PIPTAZ, VANC

Spec --ETA ----ETA

Polys Epis ----≥25/lpf <1/lpf --------<1/lpf 10-25/lpf

Organism --S. aureus ----Oral flora

PEEPmin=minimum positive end-expiratory pressure. FiO2min=minimum fraction of inspired oxygen. Tmin, Tmax=minimum temperature, maximum temperature. ETA=endotracheal aspirate. PIPTAZ=piperacillin/tazobactam. VANC=vancomycin. Spec=specimen type. Polys=polymorphonuclear leukocytes. Epis=epithelial cells. lpf=low power field.

What are the next steps, and when will the new algorithm be implemented in NHSN? • The Working Group has identified key research agenda items, which include: o Evaluation of candidate variables to use in achieving additional unit-level risk adjustment or stratification of ventilator-associated condition and complication rates.  Rates (events per 1000 ventilator days) will be stratified according to the current NHSN standard—by intensive care unit type, and for selected unit types, by bed size and academic affiliation. o Evaluation of denominator (ventilator day) data collection strategies. • The goal for implementation in NHSN is January 2013. For additional information: • Please contact the NHSN Helpdesk at nhsn@cdc.gov.

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

42 The OR Connection I www.medline.com I August 2013

NHSN Surveillance for Ventilator-Associated Events in Adults Surveillance Definitions for Ventilator-Associated Events: • For use in acute and long-term acute care hospitals and inpatient rehabilitation facilities. • For use in patients ≥ 18 years of age who are on mechanical ventilation for ≥3 calendar days. • NOTE: patients on rescue mechanical ventilation (e.g., HFV, ECMO, mechanical ventilation in prone position) are EXCLUDED. Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing FiO2 or PEEP. Baseline FiO2 and PEEP are defined by the minimum daily FiO2 or PEEP measurement during the period of stability or improvement. After a period of stability or improvement on the ventilator, the patient has at least one of the following indicators of worsening oxygenation: 1) Minimum daily FiO2 values increase ≥ 0.20 (20 points) over baseline and remain at or above that increased level for ≥ 2 calendar days. 2) Minimum daily PEEP values increase ≥ 3 cmH2O over baseline and remain at or above that increased level for ≥ 2 calendar days. Ventilator-Associated Condition (VAC)

Public Reporting Definition

On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria: 3

1) Temperature > 38 °C or < 36°C, OR white blood cell count ≥ 12,000 cells/mm or ≤ 4,000 cells/mm . AND 2) A new antimicrobial agent(s) is started, and is continued for ≥ 4 calendar days.

Infection-related Ventilator-Associated Complication (IVAC)

Public Reporting Definition

On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met:

1) Purulent respiratory secretions (from one or more specimen collections) • Defined as secretions from the lungs, bronchi, or trachea that contain >25 neutrophils and <10 squamous epithelial cells per low power field [lpf, x100]. • If the laboratory reports semi-quantitative results, those results must be equivalent to the above quantitative thresholds.

1) Purulent respiratory secretions (from one or more specimen collections—and defined as for possible VAP)

2) Positive culture (qualitative, semi-quantitative or quantitative) of sputum, endotracheal aspirate, bronchoalveolar lavage, lung tissue, or protected specimen brushing

AND one of the following: 5 • Positive culture of endotracheal aspirate, ≥ 10 CFU/ml or equivalent semi-quantitative result 4 • Positive culture of bronchoalveolar lavage, ≥ 10 CFU/ml or equivalent semi-quantitative result 4 • Positive culture of lung tissue, ≥ 10 CFU/ml or equivalent semi-quantitative result 3 • Positive culture of protected specimen brush, ≥ 10 CFU/ml or equivalent semi-quantitative result 2) One of the following (without requirement for purulent respiratory secretions): • Positive pleural fluid culture (where specimen was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube) • Positive lung histopathology • Positive diagnostic test for Legionella spp. • Positive diagnostic test on respiratory secretions for influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus

Possible Ventilator-Associated Pneumonia

Internal Quality Improvement

Probable Ventilator-Associated Pneumonia

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

August 2013 I www.medline.com I The OR Connection

Venti lato r-A ss oc iated E ven ts C E ART I C L E

The IHI Ventilator Bundle as of May 20103 • Elevation of the head of the bed 30-45 degrees unless medically contraindicated • Daily “sedation vacations” and assessment of readiness to extubate • Peptic ulcer disease prophylaxis • Deep venous thrombosis prophylaxis • Daily oral care with chlorhexidine gluconate (CHG) What’s the new focus? Oral care! Across the country organizations of all sizes are looking for tangible actions and processes that will translate into measureable results. Oral care is simple but often overlooked as having a significant role in reducing plaque and biofilm, which can travel down the aerodigestive tract potentially leading to an undesirable clinical outcome. Furthermore, in 2012 the IHI published a white paper evaluating the use of care bundles. The most revealing part of this document was the discovery that most clinical staff assumed that bundle elements were being reliably performed until they actually collected data. The data

revealed a surprisingly low level of compliance (about 10-20 percent). Reliable and consistent care has become an obvious area of needed improvement.”4 Oral care with 0.12% chlorhexidine gluconate oral rinse twice a day has been found to significantly decrease the risk of acquiring a ventilatorassociated infection. A 2009 study published in the Journal of Intensive Care Medicine found that “simple, low-cost oral care protocols can significantly decrease the rate of infection and subsequently the costs associated with these infections. The cost savings were $140,000 – $560,000 related to infection prevention of VAP. The total cost of the oral care program was $2187.49.”5

At the end of the day “it may not be an attainable goal of preventing 100 percent of HAIs, but comprehensive implementation of prevention strategies could prevent hundreds of thousands of HAIs and save tens of thousands of lives and billions of dollars.”6

So, how do we hardwire the importance of oral care into all patient care providers? Education and competency testing is the key to sustainability of clinical practices. Clinical education programs with these components can help move the needle to hospital wide compliance as opposed to unit-based compliance.

References 1. Klompas M, Kahn Y, Kleinman K, Evans RS, Lloyd JF, et al. Multicenter evaluation of a novel surveillance paradigm for complications of mechanical ventilation. PLoS One. 2011; 6(3): e18062. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3062570. Accessed June 12, 2013. 2. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams, K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection Control and Hospital Epidemiology. 2011; 32(2):101-114. 3. Implement the Ventilator Bundle. Institute for Healthcare Improvement (IHI) website. Available at: http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ Changes/ImplementtheVentilatorBundle.htm. Accessed March 4, 2013. 4. Resar R, Griffin FA, Haraden C, Nolan TW. Using care bundles to improve health care quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. Available at: http://www.ihi.org. Accessed June 12, 2013. 5. Sona CS, Zack JE, Schallom ME, McSweeney M, McMullen K, Thomas J, et al. The impact of a simple, low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. Journal of Intensive Care Medicine. 2009; 24(1):54-62. 6. Improving Surveillance Definitions for Ventilator-Associated Events: Better Surveillance=Better Care Premier Health Alliance Webinar. January 15,2013. Slides from Dr. Michael Klompas @Harvard Medical School Brigham and Women’s Hospital, Boston MA.

44 The OR Connection I www.medline.com I August 2013

The way the world looks at Ventilator-Associated Events has changed.

Medline offers everything you need. The new landscape of clinical oral care In January 2013, the Centers for Disease Control and Prevention (CDC) began a new surveillance on ventilator-associated events, with new definitions and reporting criteria. With this change comes a new way for reporting acute respiratory infections. Now you are looking not only for ventilator-associated pneumonia (VAP), but all ventilator-associated events, known as VAEs.

Contact your Medline sales representative, call 1-800-MEDLINE or visit medline.com for details on our oral care products and education.

Vulnerable and at-risk patients deserve the most aggressive care at our disposal. 1

One package, 24 hours of care Easy-to-identify kit name and rinse type. • CHG/Biotène® • CHG/Hydrogen Peroxide • Biotène only • Hydrogen peroxide only

Design makes it easy to do the right thing at the right time

Oral Care Bundle Checklist right at the point of care

Easy visual setup instructions

Fe atu r e t he n ew me d l i n e .c o m

w e N e h t Visit ine.com ts. c u l d o d Pr r e e s. t t e e m B M o utc

O . Better ter Website Bet

46 The OR Connection I www.medline.com I August 2013

medline.com The new Medline.com offers you the opportunity customize your experience by selecting your specific area of interest in healthcare. Choices include: • Hospital • Nursing Home • Home Care/Hospice • Physician Office • Surgery Center • HME Provider • Laundry • Lab All banners, clinical solutions, products and videos are customized to your chosen healthcare setting. The system remembers the setting you choose each time you come back to the site. This saves you from sifting through information that doesn’t apply to you. The new site is also optimized to work well on your mobile Internet device.

New research library More than 100 clinical studies, white papers and professional guidelines organized by topic and free to access.

New video library All videos from across the website are organized for easy access in one location.

August 2013 I www.medline.com I The OR Connection

Fe atu r e t he n ew me d l i n e .c o m

About Us Page

Updated information about our company, history, leadership and career opportunities.

Direct access to Medline University (MU)

Just click on the link and youâ&#x20AC;&#x2122;ll be connected to MU, Medlineâ&#x20AC;&#x2122;s education site for free continuing education (CE) courses and online access to Medline magazines, Healthy Skin and The OR Connection.

More ways to interact

Opportunities to email us or share content with friends and colleagues through social media. Emails go to Medline employees who are experts in the topic area of your correspondence, and we are committed to getting back to you in a timely fashion.

48 The OR Connection I www.medline.com I August 2013

New daily blog Visit often for up-to-the-minute acute and post acute care news, tips and perspectives from Medline clinical professionals and guest authors. We welcome your questions and comments to our posts.

Visit medline.com today!

Medline University

Is All-New Too!

Site design by award-winning designer Deborah Adler who also designed Medlineâ&#x20AC;&#x2122;s advanced wound care packaging that provides product education on every package.

Welcome to the new Medline University, featuring a brandnew look and improved functionality. Based on user feedback, we continue to implement changes to create a better learning environment. Take advantage of new fully customized home pages More customized than ever before, your home page will feature a custom course curriculum, participating program links, and specific courses tailored to your profile type. Streamlined and efficient, the new layout will increase staff participation and promote better outcomes.

New media options to launch course Launch courses in whatever format you choose, then proceed directly to the post-assessment when the course is finished.

View course progress on the course page Now you can find out where you are at in your course right on the course details page. Reset your course progress and even view your certificate in one easy step.

More of what you want With more of the features you wanted, the Medline University experience has been overhauled to give you more of what you want, right now.

Register now at MedlineUniversity.com to access more than 200 FREE nursing contact hours! August 2013 I www.medline.com I The OR Connection

Cari ng for your self pos it ive att i tu d e

the science behind a

positive attitude

50 The OR Connection I www.medline.com I August 2013

Wolf J. Rinke, PhD, RD, CSP

You may consider much of the positive attitude literature a bunch of hype or even psychobabble. With this article my goal is to have you consider the science, and perhaps change your perceptions about this topic, which has the potential to help you, your patients and loved ones live a healthier, more productive and longer life.

Positive Attitude and the Mind-Body Connection Scientists and physicians have explored the mind-body connection since the days of Hippocrates, the father of medicine. However, Western medicine got off to a wrong start when, in the seventeenth century, René Descartes, philosopher and founding father of modern medicine, made a deal with the Pope. You see, Descartes had a dilemma. He needed human bodies for dissection to be able to study and teach medicine. However, the Pope was not interested in giving up those bodies because the church was in charge of the soul, the mind and the emotions. So Descartes agreed that he would not in any way trespass on the church’s exclusive jurisdiction as long

as he could have the physical parts of the human body for his study. This resulted in Western medicine splitting the human body into two separate dimensions—psyche, the mind, and soma, the body—which has pervaded every scientific inquiry for the past two centuries. And it influences much of our thinking to this date. However, change—may it ever be so gradual—is taking place.

What Are Psychosomatic Illnesses? The term psychosomatic is from the Greek words psyche, which means mind, and soma, which means body. According to Mosby’s Medical Dictionary, psychosomatic illnesses, also known as psycho physiologic

disorders, refer to any of a large group of mental disorders that is characterized by the dysfunction of an organ or organ system controlled by the autonomic nervous system and that may be caused or aggravated by emotional factors. Included in this category are such common ailments as tension headaches, body pains, upset stomachs, and more serious conditions such as depression, asthma, peptic ulcers, rheumatoid arthritis, hypertension and neurodermatitis. Some physicians even include cancers. These ailments and diseases are so common that Dr. Herbert Benson, founder of the Mind Body Medical Institute at the Beth Israel Deaconess Medical Center in Boston, and author of “Timeless Healing and the Relaxation Response,” stated in a Good Morning America interview that “...60 to 90 percent of visits to healthcare professionals are in the stress-related mind-body realm where surgery doesn’t work, where medications don’t work.” Since then, numerous studies have demonstrated the importance of a positive attitude on one’s perception of well-being, wellness and health.

Positive Attitude and Health One example of the impact of a positive attitude on healing is a double-blind, randomized study of surgical patients undergoing hysterectomies. This study, which was reported in the prestigious British medical journal Lancet, found that patients who received positive messages during general anesthesia

August 2013 I www.medline.com I The OR Connection

Cari ng for your self pos it ive att i tu d e

“spent significantly less time in [the] hospital after surgery, suffered from significantly shorter period of pyrexia [fever], and made a better than expected recovery” in comparison with the group that received no such messages.

“

Research shows that when people work with a positive mindset, performance on nearly every level—productivity, creativity, engagement— improves.

”

A positive attitude can even reduce the incidence of strokes. Researchers at the University of Texas Medical Branch at Galveston reported that individuals who had a positive outlook in their later years had far fewer strokes than their negative counterparts. This major study of 2,478 men and women older than age 65 who were followed for seven years concluded “elderly folks who often feel blue tend to have more strokes than those who are not depressed.”

And optimism even appears to offer some level of protection from cancer. According to Sharot, “a study of cancer patients revealed that pessimistic patients younger than age 60 were more likely to die within eight months than non-pessimistic patients of the same initial health, status, and age.” Similarly, a study of almost 100,000 woman found that optimists had a 16 percent lower risk of having heart attacks, leading the researchers to conclude that “Optimism and cynical hostility are independently associated with important health outcomes in black and white women.”

Positive Attitude and Longevity How you express yourself may even predict how long you will live. An analysis of brief autobiographies written more than 60 years ago by a group of then-young Catholic nuns—who were participating in a study on aging and Alzheimer’s disease—revealed that those nuns who chronicled positive emotions in their 20s have lived markedly longer than those who recounted emotionally neutral personal histories. Deborah D. Danner of the University of Kentucky in Lexington and her colleagues analyzed positive emotional content in life stories written by 180 nuns when they were, on average, 22 years old. The scientists then noted which nuns had died and when. Nuns whose stories contained the most sentences expressing any of 10 positive emotions lived an average

52 The OR Connection I www.medline.com I August 2013

of 7 years longer than those whose accounts included the fewest such sentences. The researchers also found that longevity increased by 9.5 years for nuns whose life stories contained the most words referring to positive emotions and by 10.5 years for nuns who used the greatest number of different positive emotion words. Optimistic people live 19 percent longer than pessimists, according to a 30-year study conducted at the Mayo Clinic. The study, which evaluated 839 people living in Minnesota, found that people classified as optimists had a significantly better survival rate, while pessimists had a 19 percent increase in the risk of death. These findings, according to Maruta, the lead researcher in the study, “Tell us that mind and body are linked and that attitude has an impact on the final outcome, death.” Similarly, a 25-year longitudinal study of 660 people conducted at Yale University found that a positive attitude about old age was more important than wealth, gender and even cholesterol levels in determining how long people lived. In fact, people who had positive self-perceptions about aging lived 7.5 years longer than those who dreaded the thought.

Continued on page 54

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FOR AN ONLINE VIDEO DEMONSTRATION ABOUT MEDLINE’S ECODRAPE Scan this QR Code or visit www.medline.com/ecodrape

#EcoDrape greensmart™ is not a third-party certification. The use of the greensmart™ trademark is determined by Medline Industries, Inc. through an internal review process of environmental claims. ©2013 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. EcoDrape and greensmart are trademarks of Medline Industries, Inc.

Cari ng for your self pos it ive att i tu d e

Positive Attitude and Performance It seems that positivism even impacts individual and organizational performance. For example, an article in the Harvard Business Review concluded, “Research shows that when people work with a positive mindset, performance on nearly every level— productivity, creativity, engagement —improves.” In another study, researchers recorded how people express themselves in company meetings, and then take a ratio of positive to negative statements. (That is referred to as the Losado Ratio.) They found that “Companies with better than a 2.9:1 ratio for positive to negative statements are flourishing. Below that ratio, companies are not doing well economically.” On a more personal level, another researcher used the same statistic by listening to couple’s conversations and found that a Losado Ratio of 2.9:1 means that couples are headed for a divorce, while a 5:1 ratio is predictive of a strong and loving relationship.

Positive Attitude and Diseases and Illnesses These studies represent only the tip of the iceberg. Studies increasingly link attitude to the body’s propensity to ward off disease and illness. An entire new branch of medicine—referred to as psychoneuroimmunology—has been established. One of these scientists,

Dr. Candace Pert, research professor in the Department of Physiology and Biophysics at Georgetown University Medical Center and pioneer in the mind-body connection, has concluded that, “Virtually all illness … has a definite psychosomatic component … [and that] the molecules of emotion run every system in our body … this communication system is in effect a demonstration of the bodymind’s intelligence, an intelligence wise enough to seek wellness, and one that can potentially keep us healthy and disease-free … .”

It Can’t Cure Disease Before I conclude I would like to express a word of caution. What I have said in this article is that your attitudes, your thoughts, your feelings and your emotions influence your well-being, your health and probably even your longevity. I am convinced that what goes on inside of your head will control your future. It is, however, much less likely to affect what has happened in the past or what is happening in the present. In other words, if you have cancer or some other serious disease you cannot just think positive thoughts and make the disease go away! In fact, one author who suffered from cancer makes a compelling point that when tragedy strikes, anger, fear and depression are reasonable responses. And telling someone to just “think positive thoughts” may indeed be

54 The OR Connection I www.medline.com I August 2013

counterproductive. What you need to do is get expert medical treatment. Once you have received such treatment, you can use your incredible positive attitude as adjunct therapy to help you get better faster. You can also continue that type of positive programming after you have conquered the illness or disease and very likely decrease the probability of recurrence.

AV E . FA S HION S HOW J ust for fun

A Fashion Show Featuring

the little black dress of scrubs Combining her love of fashion and her interest in philanthropy, perioperative registered nurse Emma recently organized a fashion show to raise money for her hospital’s foundation. Emma has previous experience as the spokeswoman for Medline’s long sleeve PERFORMAX scrub top, which conforms with AORN and OSHA guidelines advising OR nurses who aren’t in gowns to wear long sleeves. On the following pages you will see Emma modeling Medline’s all-new AVE. line of scrubs on the runway. So, without further ado, let’s start the show!

Emma is wearing the Berkeley Ave. top in black

August 2013 I www.medline.com I The OR Connection

Featuring Medline AVE. Scrubs Emma is stunning in her Park Ave. top with accentuated waistline and Melrose Ave. pants – both in pink. Made from a soft polyester, rayon, and spandex blend, AVE. scrubs are comfortable, stylish and wrinkle resistant. The AVE. line was designed by nurses and for nurses. They told us that when they’re at work, they want to wear clothes that fit and feel like their everyday wardrobe – stylish, modern and comfortable. To check out backstage scenes from the photo shoot after the fashion show, visit www.scrubs123.com and check out the blog.

56 The OR Connection I www.medline.com I August 2013

AV E . FA S HION S HOW J ust for fun

Here’s Emma in her PerforMAX scrub top with sewn-in sleeves.

Park Ave. scrub top in purple with two front pockets and flattering V-neck.

Ocean Ave. pants in purple with a stretch panel at the waist that moves as if you were in yoga class.

Melrose Ave. pants in black.

All scrubs shown here are available exclusively through Medline’s online store at www.scrubs123.com. Bouffant cap available at www.medline.com. Medline Emma fashion doll is also available at www.scrubs123.com

August 2013 I www.medline.com I The OR Connection

early

detection could save your...

58 The OR Connection I www.medline.com I August 2013

E A R LY d etect i o n B r e a st c a nce r awareness

Life. Your breasts. Your sanity. Every person should know the symptoms and signs of breast cancer, and any time an abnormality is discovered, it should be investigated by a healthcare professional. Most people who have breast cancer symptoms and signs will initially notice only one or two, and the presence of that you have breast cancer. By performing monthly breast self-exams, you will be able to more easily identify any changes in your breast. Be sure to talk to your healthcare professional if you notice anything unusual.

August 2013 I www.medline.com I The OR Connection

Breast cancer awa r eness E ARLY detect i o n

A Change in How the Breast or Nipple Feels • Nipple tenderness or a lump or thickening in or near the breast or underarm area. • A change in the skin texture or an enlargement of pores in the skin of the breast (some describe this as similar to an orange peel’s texture). • A lump in the breast. (It’s important to remember that all lumps should be investigated by a healthcare professional, but not all lumps are cancerous.)

A Change in the Breast or Nipple Appearance • Any unexplained change in the size or shape of the breast. • Dimpling anywhere on the breast. • Unexplained swelling of the breast (especially if on one side only). • Unexplained shrinkage of the breast (especially if on one side only). • Recent asymmetry of the breasts. (Although it is common for women to have one breast that is slightly larger than the other, if the onset of asymmetry is recent, it should be checked.) • Nipple that is turned slightly inward or inverted. • Skin of the breast, areola, or nipple that becomes scaly, red, or swollen or may have ridges or pitting resembling the skin of an orange.

Any Nipple Discharge – Particularly Clear Discharge or Bloody Discharge It is also important to note that a milky discharge that is present when a woman is not breastfeeding should be checked by her doctor, although it is not linked with breast cancer.

If I have some symptoms, is it likely to be cancer? Most often, these symptoms are not due to cancer, but any breast cancer symptom you notice should be investigated as soon as it is discovered. If you have any of these symptoms, you should tell your healthcare provider so that the problem can be diagnosed and treated.

If I have no symptoms, should I assume I do not have cancer? Although there’s no need to worry, regular screenings are always important. Your doctor can check for breast cancer before you have any noticeable symptoms. During your office visit, your doctor will ask about your personal and family medical history and perform a physical examination. In addition, your doctor may order one or more imaging tests, such as a mammogram.

Source: National Breast Cancer Foundation, http://www.nationalbreastcancer.org/breast-cancer-symptoms-and-signs

60 The OR Connection I www.medline.com I August 2013

Yes, They’re Genuine. Only Generation Pink Pearl® gloves combine aloe, nitrile and breast cancer awareness.

Join the Pink Glove Nation and participate in the 2013 Pink Glove Dance Competition. For more information on Medline’s Breast Cancer Awareness campaign, visit www.pinkglovedance.com.

Pink Glove Dance Competition 2013 Key dates October 4 Submission of videos ends October 25 Voting begins November 15 Winners announced

Bigger Prizes Winners receive a cash prize to donate to the breast cancer charity of their choice.*

First Place: $25,000 Second Place: $10,000 Third Place: $5,000

* Charity must be approved by Medline Industries, Inc.

NEW Award Catagories • Artist’s choice • Best choreography • Best story • Most people • Most recorded views • Largest donation to a breast cancer charity

2012 Pink Glove Dance Winner Lexington Medical Center West Columbia, South Carolina

Competition’s Song List

Outasight Tonight Is the Night

Krewella Alive

Outasight Change the World

Sara Bareilles Brave

Bruno Mars Treasure

One Direction What Makes You Beautiful

Fun. Carry On

Greg River Ordinance Rise Up

98º Impossible Things

@PinkGloveDance

/PinkGloveDance

@PinkGloveDance Use Hashtag: #PinkGloveDance and #2013PGD in August 2013 I www.medline.com I The OR Connection tweets, photos, pins, and other social media posts

A World Without Breast Cancer Is Within Our Reach In 2005, Medline launched a breast cancer awareness campaign with a single vision: A World Without Breast Cancer Is Within Our Reach. Nearly a decade later, Medlineâ&#x20AC;&#x2122;s campaign has helped make significant strides to improve the lives of everyone affected by the disease â&#x20AC;&#x201C; patients, survivors, families of those who lost their battle, healthcare workers, to name a few.

We are proud to partner with the National Breast Cancer Foundation (NBCF) because we share in their mission to save lives through early detection and to provide free mammograms to those in need. Medline implements a variety of activities throughout the year that support our breast cancer education, awareness and fundraising goals. Here are some highlights:

64 The OR Connection I www.medline.com I August 2013

Pink Product Line Medline donates a portion of the proceeds from the sale of Medline brand PINK products including our signature pink gloves, scrubs, physician gowns, masks and caps, to the NBCF. www.scrubs123.com and click Shop PINK!

ME DLINE & NBC F Brea st Ca ncer Awareness

Education In addition to our breast cancer awareness page on medline.com, we also host Beyond the Shock®, the NBCF’s education portal on Medline University. Beyond The Shock is a free, comprehensive guide to understanding breast cancer, early detection and treatment options. www.medlineuniversity.com and click Patient Education

Pink Glove Dance Competition Medline celebrates the millions of people affected by breast cancer through our Pink Glove Dance competition. It provides our customers a unique opportunity to build morale in their facility and engage their community in a common cause. www.pinkglovedance.com

Annual Breast Cancer Awareness Breakfast Since 2006, Medline has hosted its Annual Breast Cancer Awareness Breakfast at the Association of periOperative Registered Nurses (AORN) Annual Congress. It has become a “must-attend” event, attracting more than 1,000 guests. www.medline.com/special/aorn-2013/ index.html

August 2013 I www.medline.com I The OR Connection

Reci pe Lemo n bread

Nutrition Information Servings: 12 Fat: 9.6 g Fiber: 9.1 g Calories: 229 per slice Sodium 27 mg

Lemon bread Rachel Druschel has worked for Medline for seven years. She was a sales representative in Indianapolis for five years, and for the past two years she has been serving as director of sales training at Medline’s corporate headquarters in Mundelein, IL. Her lemon bread comes from a family recipe that her grandma “Bubba” makes for all of their family functions. “I hope it wasn’t a secret recipe!” Rachel joked. Rachel said she loves cooking and especially enjoys using a recipe as a guide – not following it exactly, and making the meal her own. “Cooking is a great thing to do to take a break from the stress of life. Many people work out to relieve stress, but for me, working out is when I work through my problems; however, when I cook nothing else seems to matter. I enjoy cooking for friends and family—and even strangers,” she said. 2 The Medline employee cookbook is $10. To purchase your own copy, please e-mail Judy at jdesalvo@medline.com.

66 The OR Connection I www.medline.com I August 2013

Ingredients for topping: ¼ cup sugar Juice of 1 lemon Ingredients for bread: ½ cup butter, margarine or other shortening 1 cup sugar 2 eggs 1½ cups flour 1½ teaspoons baking powder Pinch of salt 1 lemon rind, grated ½ cup milk Directions

For topping: Mix sugar and lemon juice together before starting bread. Set aside. You will pour this mixture over the bread as it is cooling. For bread: Stir together flour and baking powder. Cream shortening and sugar. Add eggs one at a time and beat well. Add pinch of salt and lemon rind. Alternate adding flour mixture and milk into the cream mixture. Pour batter into a greased and floured loaf pan. Bake at 350 degrees F for 40-45 minutes. Place bread on cooling rack, and then pour the topping over the bread as it cools. Do not put the bread back in the oven after you have poured on the topping.

Fo r m s & Tools

The following pages contain practical tools for implementing patient-focused care practices at your facility.

Infection Prevention Ventilator-Associated Pneumonia FAQs (English) …...…………………...…69 Ventilator-Associated Pneumonia FAQs (Spanish) …...………………...…..72 Ventilator-Associated Event Data Worksheet ...…...…….....…………...…..75

August 2013 I www.medline.com I The OR Connection

Medline Cath Lab Kits:

Your Experience Goes In Every One. You design the cath lab kit that best fits your practice. Medline builds it with precision and value. And now with complete fluid management and other high quality components, your cath lab kit truly will be just what the doctor ordered.

1-800-MEDLINE I www.medline.com Start building your neÂw cath lab kit today with our latest cath lab components catalog. #CathLabKits

ÂŠ2013 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Fo r m s & T ools VA P FA Q S

FAQs (frequently asked questions)

about

“Ventilator-Associated Pneumonia”

What is a Ventilator-Associated Pneumonia (VAP)? A “pneumonia” is an infection of the lungs. A “ventilator” is a machine that helps a patient breathe by giving oxygen through a tube. The tube can be placed in a patient’s mouth, nose, or through a hole in the front of the neck. The tube is connected to a ventilator. A “ventilator-associated pneumonia” or “VAP” is a lung infection or pneumonia that develops in a person who is on a ventilator. Why do patients need a ventilator? A patient may need a ventilator when he or she is very ill or during and after surgery. Ventilators can be life-saving, but they can also increase a patient’s chance of getting pneumonia by making it easier for germs to get into the patient’s lungs. What are some of the things that hospitals are doing to prevent ventilator-associated pneumonia? To prevent ventilator-associated pneumonia, doctors, nurses, and other healthcare providers: • Keep the head of the patient’s bed raised between 30 and 45 degrees unless other

medical conditions do not allow this to occur.

• Check the patient’s ability to breathe on his or her own every day so that the patient Keep the head of the patient s bed can be taken off of the ventilator as soon as possible. raised between 30 to 45 degrees. • Clean their hands with soap and water or an alcoholbased hand rub before and after touching the patient or the ventilator. • Clean the inside of the patient’s mouth on a regular basis. • Clean or replace equipment between use on different patients. What can I do to help prevent VAP? • If you smoke, quit. Patients who smoke get more infections. If you are going to have surgery and will need to be on a ventilator, talk to your doctor before your surgery about how you can quit smoking.

August 2013 I www.medline.com I The OR Connection

VAP FAQ s Form s & Tools

• Family members can ask about raising the head of the bed. • Family members can ask when the patient will be allowed to try breathing on his or her own. • Family members can ask doctors, nurses, and other healthcare providers to clean their hands. If you do not see your providers clean their hands, please ask them to do so. • Family members can ask about how often healthcare providers clean the patient’s mouth. Can VAP be treated? VAP can be a very serious infection. Most of the time, these infections can be treated with antibiotics. The choice of antibiotics depends on which specific germs are causing the infection. Your healthcare provider will decide which antibiotic is best. If you have questions, please ask your doctor or nurse.

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70 The OR Connection I www.medline.com I August 2013

Clean Hands

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Proven. Exceeds the world’s strictest hand hygiene guidelines.1 Effective. A quick pump kills 99.999% of most germs in 15 seconds.2 Gentle. Skin emollients soften without stickiness.

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Reference: 1. World Alliance for Patient Safety. WHO Guidelines in Hand Hygiene in Health Care, Global Patient Safety Challenge, Clean Care is Safer Care. 2009. 2. Time Kill Test. Data on file. ©2013 Sterillium is a registered trademark of Bode Chemie GmbH and distributed by Medline Industries, Inc.

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Form s & Tools VAP FAQS E SPAÑ O L

Preguntas frecuentes

“Neumonía asociada al ventilador”

¿Qué es la neumonía asociada al ventilador? La “neumonía” es una infección en los pulmones. Un “ventilador” es una máquina que le ayuda al paciente a respirar por medio de un tubo que le proporciona oxígeno. El tubo puede ponerse en la boca, nariz o por medio de un orificio en el cuello del paciente. El tubo se conecta al ventilador. La “neumonía asociada al ventilador” es una infección de los pulmones o neumonía que se desarrolla en la persona que está conectada al ventilador. ¿Por qué los pacientes necesitan el ventilador? Un paciente puede necesitar el ventilador cuando está muy enfermo o durante y después de una cirugía. Los ventiladores pueden salvarle la vida, pero también aumentan las probabilidades del paciente de contraer neumonía al facilitar la entrada de los gérmenes en los pulmones. ¿Cuáles son algunas de las medidas que los hospitales están tomando para prevenir la neumonía asociada al ventilador? Para prevenir la neumonía asociada al ventilador, los doctores, enfermeras y otros proveedores de atención médica: • Mantienen elevada la cabecera de la cama del paciente entre 30 y 45 grados, a menos que existan otras condiciones médicas que lo prohíban. • Todos los días evalúan la habilidad del paciente 30� a 45� para respirar por sí mismo, por si pueden quitarle el ventilador lo más pronto posible. Mantenga elevada la cabecera de la • Se lavan las manos con agua y jabón o usan un cama del paciente entre 30 a 45 grados. desinfectante para manos a base de alcohol antes y después de tocar al paciente o el ventilador. • Frecuentemente le limpian la boca al paciente. • Limpian o reemplazan el equipo entre cada uso con diferentes pacientes.

72 The OR Connection I www.medline.com I August 2013

VA P FA Q s E S PA Ño L Fo r ms & Tools

¿Qué puedo hacer para ayudar a prevenir la neumonía asociada al ventilador? • Si usted fuma, deje de hacerlo. Los pacientes que fuman contraen más infecciones. Si usted va a tener cirugía y va a necesitar usar un ventilador, hable con su doctor antes de la cirugía sobre cómo puede dejar de fumar. • Los familiares pueden preguntar si pueden levantar la cabecera de la cama. • Los familiares pueden preguntar cuándo se le permitirá al paciente intentar respirar por sí mismo. • Los familiares pueden pedirle a los doctores, enfermeras y otros proveedores de atención médica que se laven las manos. Si usted no ve a sus proveedores de atención médica lavarse las manos, por favor pídales que lo hagan. • Los familiares pueden preguntar a los proveedores de atención médica la frecuencia en que le limpian la boca al paciente. ¿Puede tratarse la neumonía asociada al ventilador? La neumonía asociada al ventilador puede ser una infección muy grave. En la mayoría de los casos, estas infecciones pueden tratarse con antibióticos. El antibiótico se elige dependiendo del germen específico que está causando la infección. Su proveedor de atención médica decidirá qué antibiótico es mejor para usted. Si tiene preguntas, por favor hágaselas a su doctor o enfermera.

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August 2013 I www.medline.com I The OR Connection

SAFER CATHETERIZATION FOR KIDS Pediatric Catheter Tray

Children’s Activities

Medline’s Pediatric Catheter Tray. The newest addition to the innovative ERASE CAUTI™ product line.

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You trust Medline for clinical innovations, such as our industry-leading catheter tray design. Now, we can be your patient’s buddy, too.

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Sometimes, you just need a buddy. Buddy the Brave lion cub is here to help your youngest catheter patients. Along with some serious patient (and parent) education resources, you’ll find some upbeat fun and even a bravery award sticker in every tray.

PEEP Min

FiO 2 Min

Step 1: VAC (change in A or B)

Min [<36⁰C]

Max [>38⁰C]

C. Temp

Min [≤4K)

Max [≥12K]

D. WBC

QAD ()

Step 2: IVAC (VAC, plus C or D, and E)

Purulent respir-‐ atory secre-‐ a tions ()

i. Any sputum cx, or qual cx of BAL, ETA, PSB, lung tissue ()

b ,c

ii. Meets semi-‐quant or quant criteria (BAL, PSB, ETA, lung d tissue cx) ()

G. Positive culture

Pleural fluid ()

Path ()

Legionella or viral diagnostic ()

H. Other positive PrVAP e criteria

Step 3: PoVAP (IVAC, plus F or G) —OR— PrVAP (IVAC, plus [F and Gii] or IVAC, plus H)

VAE (VAC, IVAC, PoVAP, PrVAP)

Abbreviations: Vent = ventilator; PEEP = Positive End-‐Expiratory Pressure; FiO2 = fraction of inspired oxygen; Min = daily minimum; Max = daily maximum; ≤4K = ≤4,000 WBC/mm ; ≥12K = ≥12,000 WBC/ mm ; QAD = Qualifying Antimicrobial Day (see Antimicrobial Worksheet or protocol for details); cx = culture; BAL = bronchoalveolar lavage; PSB = protected specimen brush; ETA = endotracheal aspirate; qual = qualitative (non-‐ quantitative); quant = quantitative; PrVAP = Probable VAP; Path = pathology/histopathology; VAC = Ventilator-‐Associated Condition; IVAC = Infection-‐related Ventilator-‐Associated Complication; PoVAP = Possible VAP. a ≥25 neutrophils per low power field [lpf, x 100] (or heavy, 4+) and ≤10 squamous epithelial cells per low power field [lpf, x 100] (or rare, occasional, few, 1+ or 2+) b 5 4 4 ETA: quantitative threshold ≥10 CFU/ml (or moderate-‐heavy, 2+-‐4+ growth); BAL: quantitative threshold ≥10 CFU/ml (or moderate-‐heavy, 2+-‐4+ growth); Lung tissue: quantitative threshold ≥10 CFU/g (or moderate-‐ 3 heavy, 2+-‐4+ growth); PSB: quantitative threshold ≥10 CFU/ml (or moderate-‐heavy, 2+-‐4+ growth) c Excludes the following, when cultured from sputum, ETA, BAL, PSB: Normal respiratory/oral flora, mixed respiratory/oral flora or equivalent, Candida species or yeast not otherwise specified, coagulase-‐negative Staphylococcus species, Enterococcus species. Exclusions do not apply to cultures of lung tissue or pleural fluid. d Semi-‐quantitative and quantitative culture criteria apply to BAL, PSB, ETA and lung tissue cultures only (not to sputum cultures). e Any of the following can be used to meet the PrVAP definition: 1) positive pleural fluid culture where specimen was obtained during thoracentesis or initial placement of chest tube; 2) lung histopathology (see protocol for guidance); 3) positive diagnostic test for Legionella spp. or for the following respiratory viruses: influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus

Vent Day

Date

PATIENT ID_________________________

Ventilator-‐Associated Event Data Collection Worksheet

VA E DATA C O L L E C T ION Fo r m s & Tools

August 2013 I www.medline.com I The OR Connection

NEW!

You’ll never see packs the same again. Organized. Efficient. Simple.

The purpose of surgical procedure packs is to bring convenience to your world. Yet every blue pack looks almost identical to every other pack – resulting in needless confusion and costly mistakes. Wrong packs are pulled more often than you might think - causing the extra work and expense of pulling separate sterile items. Or, worse yet, discarding the entire wrong pack and replacing it with the correct one. Furthermore, when looking at the pack insert, it's difficult to identify important information such as its contents, expiration date or if any of the contents contains latex. Recognizing these problems, Medline set out to eliminate pack confusion. The result: Medline’s EMPOWER Packaging System – an entirely new and streamlined way of looking at packs.

Turn to page 28 for the complete story behind the innovative design!

Visit us at the OR Manager Conference! Booth #615 September 23-25, 2013 #EmpowerOR

Email us at empower@medline.com, or call 1-800-MEDLINE to learn more about how EMPOWER Surgical Packs can transform your OR. ©2013 Medline Industries, Inc. Medline and Empower are registered trademarks of Medline Industries, Inc.

MKT1329171 / LIT304R / 25M / JBK5