New Joint Commission center to take on wrong-site surgery · partment says its investigation...

November 2009 Vol 25, No 11

The monthly publication for OR decision makers

In this issueScrub tech pleads guilty in hepatitis case ..........................5

ECONOMIC TRENDS.Hernia, total joint volumes down............................7

PATIENT SAFETY.NoThing Left Behind...............10

PATIENT SAFETY.A 4-year effort to prevent retained items ...........................12

SALARY/CAREER SURVEY.OR business manager gains ground.............................17

INFECTION CONTROL.Tackling an outbreak of MRSA SSIs ............................21

Six hospitals settle with feds over Medicare claims for kyphoplasty ........................24

OR BUSINESSMANAGEMENT.Avoiding inpatient-only claims pitfalls............................25

AMBULATORY SURGERYCENTERS.ASCs weigh impact of Medicare pay ............................26

AMBULATORY SURGERYCENTERS.ASCs can benchmark quality data ...............................28

AT A GLANCE.........................32

ASC section on page 26.

Preventing retained surgical items:What role does technology play?

New Joint Commission center to take on wrong-site surgery

Alot of effort has gone intopreventing wrong surgerythrough the Joint Commis-

sion’s Universal Protocol and othermeasures.

Still, the data suggest the inci-dence hasn’t changed very much.The Joint Commission estimatesabout 40 wrong surgery cases hap-pen every week in this country. Thenumbers are projected from Min-nesota and Pennsylvania, 2 statesthat have mandatory reporting.

A new Joint Commission initia-tive is aiming for breakthroughs on

this and other persistent problemslike hand-washing failure andcommunication breakdowns dur-ing hand-offs, failures that harmthousands of patients and cost bil-lions of dollars a year.

The Joint Commission’s newCenter for Transforming Health-care, rolled out September 10, 2009,teams with groups of hospitals toapply quality improvement meth-ods long used by industry likeLean Six Sigma. The intent is to de-velop “targeted practical strate-

Apatient needs major sur-gery to remove 5 laparo-tomy sponges left behind

during a previous case. The inves-tigation finds that during an ex-ploratory laparotomy, the circulat-ing nurse introduced a 5-pack ofsponges into the sterile field butdid not enter the count on theworksheet or white board. Reliefstaff were not aware of the extra 5sponges, and the count later ap-peared correct. The incident is 1 of6 retained-item cases that resultedin $25,000 fines for California hos-pitals in September 2009.

What does it take to eliminate

the rare but stubborn problem ofretained items?

Though the incidence is un-known, estimates are that an itemis left behind in from 1 in 1,000 to1,500 abdominal operations and 1in every 8,000 to 18,000 inpatientoperations.

Medicare has a policy to nolonger pay an additional amountfor treatment associated with re-tained surgical items. Insurancecompanies have followed suit.

Could technology such as bar-coded or radiofrequency taggedsponges help prevent retained

Continued on page 6

Continued on page 8

Patient safety

Performance improvement

Educate to Improve Performance

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To receive additional information on the Certificate of Mastery Programs contact CCI at 888.257.2667.

3OR Manager Vol 25, No 11November 2009

Every year, we honor an ORManager of the Year. Lastmonth, we introduced you to

this year’s honoree, Elena Canacari,RN, CNOR, director of periopera-tive services at Beth Israel DeaconessMedical Center in Boston.

The award, in honoring an indi-vidual manager, also honors all ORmanagers and their important con-tributions.

Candidates are nominated bytheir colleagues. This year’s nomi-nating letters portray leaders whomentor and support their staffs, ad-vocate for patients and professional-ism, and do their utmost to run theirdepartments in a safe and cost-effec-tive manner.

We’d like to introduce you to afew of them.

Guillermo Abogado“He takes on patient care at every

level,” a colleague wrote of GuillermoAbogado, RN, director of nurses atthe Center for Special Surgery at theTexas Center for Athletes in San Anto-nio. Known as “G,” Abogado led themove to a new surgery center andshepherded it through accreditation,working with 15 physician partners.He can also be found at the bedsidecaring for patients.

“’G’ has won my respect overand over again,’” wrote SharonWaite, RN, BSN.

Janet Dauphinee Quigley“Janet is one of the most passion-

ate and successful leaders we havehad the honor of working with; shehas a clear vision and a devotedstaff,” wrote 5 RN colleagues in nom-inating Janet Dauphinee Quigley,RN, MSN, nurse director of the SameDay Surgery Unit at MassachusettsGeneral Hospital in Boston.

Among her achievements, Quig-ley led the development of a re-gional block program in collabora-tion with the anesthesia team, bring-ing together all disciplines.

“She guides the staff with pa-tience and a quiet wisdom that in-spires dedication,” her colleaguessaid.

Regina ZnoskoNurse and physician colleagues

lauded Regina Znosko, RN, BSN,CNOR, for the high standards sheupholds as surgical services leaderat Gwinnett Medical Center inLawrenceville, Georgia.

Surgeon Don W. Penney, MD,wrote that Znosko has seen herworkload expand beyond the OR toencompass outpatient surgery, therecovery room, and preop care, aswell as construction projects.

“Regina has the capacity and willto rally her employees and peers to acommon purpose, that being excel-lence in patient care and safety,growth and self-improvement bothindividually and collectively.”

We would like to thank themany OR professionals who wroteon behalf of their leaders. It’s awonderful reminder of the serviceour readers and their colleaguesgive every day. �

—Pat Patterson

The OR Manager of the Year is honoredat the annual Managing Today’s ORSuite Conference and receives an ex-pense-paid trip to the meeting.

Do you know someone who should behonored? Watch for the announcementfor 2010 nominations in coming issuesof OR Manager.

Upcoming

November 2009 Vol 25, No 11OR Manager is a monthly publication forpersonnel in decision-making positions inthe operating room.

Elinor S. Schrader: Publisher

Patricia Patterson: Editor

Judith M. Mathias, RN, MA: Clinical editor

Kathy Shaneberger, RN, MSN, CNOR:Consulting editor

Paula DeJohn: Contributing writer

Karen Y. Gerhardt: Art director

OR Manager (USPS 743-010), (ISSN8756-8047) is published monthly by ORManager, Inc, 1807 Second St, Suite 61,Santa Fe, NM 87505-3499. Periodicalspostage paid at Santa Fe, NM and addi-tional post offices. POSTMASTER: Sendaddress changes to OR Manager, PO Box5303, Santa Fe, NM 87502-5303.

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Copyright © 2009 OR Manager, Inc. Allrights reserved. No part of this publica-tion may be reproduced without writtenpermission.

Subscription rates: Print only: domestic $99per year; Canadian $119 per year; foreign$139 per year. Super subscriptions (in-cludes electronic issue and weekly elec-tronic bulletins): domestic $149 per year;Canadian $169 per year; foreign $179 peryear. Single issues $24.95. Subscribe onlineat www.ormanager.com or call 800/442-9918 or 505/982-1600. Email: [email protected].

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Editorial


Heading off drug diversionSteps to prevent pilfering by

staff and physicians.

New accrediting body Get to know DNV, a new hospi-

tal accrediting organization. What isit like to go through a DNV survey?

“

“The award honors all OR

managers.


Aformer surgical technicianwho apparently infectedmore than a dozen pa-

tients with hepatitis C by stealingfentanyl and placing used sy-ringes back on anesthesia cartspleaded guilty September 25,2009, to federal charges of tam-pering and theft, the Denver Postreported.

Kristen Diane Parker, 26, facessentencing in December for 10 ofthe 38 counts against her. The rec-ommended sentence is 20 years inprison. Remaining counts weredismissed. Parker agreed to fur-ther blood testing and other stepsneeded to address victim issues.

Parker admitted she stole thefentanyl while employed at RoseMedical Center in Denver betweenOctober 2008 and April 2009 and atAudubon Surgery Center in Col-orado Springs in May and June2009, according to the plea agree-ment. About 6,000 patients hadsurgery at the facilities during thetime Parker worked there.

As of September 25, 26 patientsfrom Rose had positive HCV testsepidemiologically linked to Parker,and 15 had been positively linkedto the case by more definitive viralsequencing analysis, the Coloradohealth department reported. Onepatient who tested positive atAudubon was initially linked toParker, but the link was not borneout by viral sequencing.

Contaminated syringesAccording to the plea agree-

ment, Parker, who was infectedwith hepatitis C, while employedas a scrub tech at the 2 facilitiesstole fentanyl syringes from ORs,

injected herself with the drug,and replaced the syringes on theanesthesia carts with used saline-filled syringes, which were thenused on patients.

Parker acknowledged she waspositive for hepatitis C when shestarted working at Rose, accord-ing to the plea agreement. InMarch 2009, a Rose employee re-ported she was stuck by a needlein Parker’s scrub top pocket, andshe had found Parker in an OR towhich she was not assigned.Parker was questioned but denieduse of narcotics, and a drug testwas negative for narcotics.

A few weeks later, Parker wasagain found in an OR to whichshe was not assigned. She claimedto be setting up for the nextsurgery. She was immediatelyscreened for drugs. The test cameback positive for fentanyl, andshe was fired. Rose reported theincident to the health departmentand Drug Enforcement Adminis-tration. Meanwhile, Parker soughtemployment at Audubon, askingthat Rose not be contacted as areference.

Health departrmentinvestigates

About the same time, thehealth department received 9 pos-itive HCV tests from patients whohad had surgery at Rose. The de-partment says its investigationsuggested the infections werecaused by exposures duringsurgery and coincided withParker ’s employment there.Parker was originally charged inJuly 2009 with tampering andother drug-related charges.

Rose notified about 4,700 pa-tients who had surgery during thetime of Parker’s employment, andAudubon notified about 1,200. �

Renae Battié, RN, MN, CNORRegional director of perioperative services, Franciscan Health System, Tacoma, Washington

Ramon Berguer, MDChief of surgery, Contra Costa Regional Med-ical Center, Martinez, California

Mark E. Bruley, EIT, CCEVice president of accident & forensic investigation, ECRI, Plymouth Meeting, Penn-sylvania

Jayne Byrd, RN, MSNAssociate vice president, surgical services, Rex Healthcare, Raleigh, North Carolina

Robert G. Cline, MDMedical director of surgical services, MunsonMedical Center, Traverse City, Michigan

Franklin Dexter, MD, PhDProfessor, Department of anesthesia and healthmanagement policy, University of Iowa, IowaCity

Dana M. Langness, RN, BSN, MASenior director, surgical services, Regions Hospital, St Paul, Minnesota

Kenneth Larson, MDTrauma surgeon, burn unit director, Mercy St John’s Health Center, Springfield, Missouri

Kathleen F. Miller, RN, MSHA, CNORSenior clinical consultant, Catholic Health Ini-tiatives, Denver

David A. Narance, RN, BSN, CRCSTManager, sterile processing, MedCentralHealth System, Mansfield, Ohio

Shannon Oriola, RN, CIC, COHNLead infection control practitioner, Sharp Metropolitan Medical Campus, San Diego

Cynthia Taylor, RN, BSN, MSA, CGRNNurse manager, Endoscopy & BronchoscopyUnits, Hunter Holmes McGuire VA MedicalCenter, Richmond, Virginia

Dawn L. Tenney, RN, MSNAssociate chief nurse, perioperative services,Massachusetts General Hospital, Boston

Judith A. Townsley, RN, MSN, CPANDirector of clinical operations, perioperative services, Christiana Care Health System, Newark, Delaware

Ena M. Williams, RN, MSM, MBANursing director, perioperative services, Yale-NewHaven Hospital, New Haven, Connecticut

Terry Wooten, Director, business & material re-sources, surgical services & endoscopy, St Joseph Hospital, Orange, California

Advisory Board

Scrub tech pleads guilty in hepatitis case

“

“The recommendedsentence is 20

years.

gies,” Joint Commission PresidentMark Chassin, MD, MPP, MPH,said at a press conference.

The Joint Commission says itwill share the strategies, such as as-sessment tools and packages of in-terventions, with accredited facili-ties at no extra cost.

The program is separate fromaccreditation today. But Dr Chassinsaid over time the commission willconsider building elements thatwork into accreditation require-ments.

Beyond easy fixesThe center will start by tackling

3 issues:• hand hygiene• preventing wrong surgery• hand-off communication.

Eight hospitals volunteered forthe hand hygiene initiative, amongthem Cedars-Sinai Health Systemin Los Angeles and Johns HopkinsHospital in Baltimore.

As the group began digging intothe issue, Dr Chassin said theyfound the problems were “beyondeasy fixes.“ Among barriers theydiscovered were not having soapand hand-rub dispensers in conve-nient places and faulty data thatled the hospitals to think hand-cleaning rates are better than theyare. On average, caregivers actu-ally were cleaning their hands lessthan 50% of the time.

Targeted solutions are nowbeing tested, such as holdingeveryone accountable and respon-sible—physicians, nurses, techni-cians, therapists, housekeepers,and others and using a reliableway to measure performance.

Wrong-surgery initiativeTwo hospitals will work on pre-

venting wrong surgery, Rhode Is-land Hospital, a large teaching cen-ter, and Newport Hospital, a com-

munity facility, both part of theLifeSpan system based in Provi-dence, Rhode Island. Hospitals inthe state have had several widelyreported wrong-surgery incidents.

Given the effort already spent onprevention, what can this initiativeadd? Rhode Island hospitals spent 2years developing a statewide surgicalsafety protocol introduced in July2009 (September 2008 OR Manager).

Mary Cooper, MD, JD, LifeSpan’schief quality officer, told OR Managershe and other leaders see an opportu-nity to introduce tools like Lean SixSigma, which the hospitals do notcurrently have experience with.

The heart of the matter“We wanted to do something

about preventing wrong surgerythat gets to the heart of the matter,”she says. The Joint Commissioncenter is providing LifeSpan with 2Six Sigma Black Belts, one ofwhom is a surgeon, and a “masterchange agent” for the wrong-sitesurgery project. They are workingwith front-line staff as well asphysicians. The project started inJuly 2009, with results expected bynext spring or summer.

Focus on variationThe wrong-site project is focus-

ing on 2 areas, Dr Cooper explains.Newport Hospital will look at

standardizing surgical site mark-ing. Though site marking has beenan expectation for a long time, shenotes, there is variation. For exam-ple, even if everyone in a hospital

signs, “yes,” there still are differ-ences in the distance from themark to the incision site and in thesize of the mark.

At Rhode Island Hospital, thefocus will be on situations wherethere are inherent variations, mak-ing it difficult to mark the site. Ex-amples are procedures where therewill be 2 incisions on the same sideor where a laparoscope will be in-serted in a different location thanthe intended procedure.

“As we talk to colleagues aroundthe country, we have found that pro-cedures that are done incorrectlyand are near misses tend to be oneswhere people scratch their headsand say, ‘I’ve never come up againstthis before,’” Dr Cooper says. “It isnot the routine procedures wherepeople are making mistakes.”

The hospital will also look atsurgical site verification in emer-gencies, when care is rushed.

Stepping forward“It was very important to us to

step forward and tackle this prob-lem, in large part because we havehad wrong-site procedures aboutwhich we and the state have beenvery vocal,” she says.

“It was important for us to say,not only are we going to be open,but we want to be out there look-ing for innovative approaches tomake sure this doesn’t happen tothe next patient.”

The Joint Commission said thecenter has received support fromthe American Hospital Association,the Federation of American Hospi-tals, and companies including BD,Ecolab, GE Healthcare, and John-son & Johnson. �

Learn more about the Joint Commis-sion Center for Transforming Health-care at www.centerfortransform-inghealthcare.org/

6 OR Manager Vol 25, No 11 November 2009

Performance improvement

Continued from page 1

“

“What can this initiative

add?


Three elective surgical proce-dures saw declines in early2009 for a group of facilities

participating in the OR Bench-marks Collaborative.

Hernia repair and total hip andtotal knee replacement volumeswere down in January throughJuly compared with the same pe-riod the year before. Declines were:• Hernia repair: minus 7% • Knee replacements: minus 11%.• Hip replacements: minus 6%.

The data are from 12 months ofdata submitted to the collaborativeby 130 US hospitals and 14 ambu-latory surgery centers (ASCs). Ofthe hospitals, 88% were commu-nity facilities, and 12% were acade-mic centers.

Geographic distribution was: • North Atlantic: 32%• South Atlantic: 28%• Midwest: 16%• West: 24%.

The recession and electivesurgery

The impact of the recession onelective surgery has been hard togauge.

As the downturn hit in late2008, press reports quoted hospitalexecs as saying volumes of electivecases were falling, as people post-poned care because of the loss ofjobs and insurance.

In a survey by the AmericanHospital Association in March2009, 59% of members had seen amoderate to significant decline inelective procedures.

OR directors interviewed by ORManager in February 2009 reporteduneven effects—for some, volumewas down, but for others it waseven or a little ahead.

In the 2009 OR Manager Salary/Career Survey, 30% of respondents

from hospital ORs reported a de-crease in surgical volume, comparedwith 24% in 2008. For ASCs, 90%had seen a decrease in electivesurgery (October 2009 OR Manager).(The hospital OR survey did notask specifically about elective vol-ume.)

In August 2009, Thomson Reutersreported hospital finances recoveredsomewhat in the first quarter of theyear, based on benchmarking datafrom 522 hospitals. The report doesnot include elective surgery.

Other Thomson Reuters data-bases had not shown much change

in elective surgery. Only in June andJuly did the company see a down-ward trend for elective proceduressuch as screening colonoscopy andknee arthroscopy, but the trend wasnot strong, according to a spokes-man. �

The OR Benchmarks Collaborative is apartnership of OR Manager, Inc, andMcKesson that offers benchmarking onkey performance indicators. More information is at www.orbenchmrking.com

Hernia, total joint volumes downEconomic trends

Hernia repair volume

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items? Three technologies areavailable (sidebar, p 9).

OR leaders whose facilities haveadopted technology caution that itis not a substitute for manualcounting and other preventivemeasures.

“This is a big change in OR cul-ture, and it cannot just be throwninto the OR without preparationfor everyone,” says Robert Cima,MD, MA, chair of the surgicalquality committee at the MayoClinic in Rochester, Minnesota. TheClinic has introduced scanning ofbar-coded sponges as part of a 4-year project to prevent retained

items (relatedarticle, p 12).How the tech-nology is im-plemented andthe culture intowhich it is in-troduced are

more important than the technol-ogy itself, he notes.

Common themes Leaders in organizations that

have adopted sponge-trackingtechnology stress these commonthemes:• Staff and physicians must be in-

volved in planning and imple-menting any solution to preventretained items.

• Implementation needs to be care-fully planned and include thor-ough communication and educa-tion.

• Team communication and collab-oration are essential to preven-tion.

‘You have tocommunicate’

A recent study Dr Cima led atMayo found communication break-downs were the most common rootcause of retained items.

“The technology is great, but itdoesn’t take the place of count-ing—and you have to communi-cate with each other,” stressesCheryl Weisbrod, RN, MS, nurseadministrator of surgical servicesat the Mayo Clinic in Rochester.

The real work is “to change thebehavior of the nurses and sur-geons to have them work to-gether,” adds Verna Gibbs, MD, asurgeon who developed the No-Thing Left Behind campaign toprevent retained items (sidebar, p10). She is a professor of clinicalsurgery at the University of Cali-fornia, San Francisco (UCSF) and asurgeon at the San Francisco Veter-ans Affairs Medical Center.

Low-tech and high-tech The UCSF Medical Center

adopted the bar-coded spongetechnology (SurgiCount Medical)more than 2 years ago as part of amultidisciplinary effort.

Perioperative nurses at UCSFalso worked with Dr Gibbs in de-veloping a standardized low-techmethod for verifying that allsponges are accounted for. Themethod, called the Sponge AC-COUNTing system, uses inexpen-sive plastic hanging sponge hold-ers and dry erase boards to keeptrack of sponges. (See September2008 OR Manager.)

The use of the hanging spongeholders adds about 30 cents perholder to total case costs, Dr Gibbssays.

Sandra Wienholz, RN, MSN, pa-tient care manager in the MoffittLong ORs at UCSF, says, “Nurseshave to be very confident in theirpractice before you add technology.As our technical and patient care re-sponsibilities increase, our spongecounting practice has to be strong.”(At the time UCSF adopted bar-coded sponges, technologies usingradiofrequency energy had not yet


Patient safety

Continued from page 1Retained items:Fast facts

Estimates are that a foreignbody is retained:• in 1 in every 1,000 to 1,500 ab-

dominal operations• in 1 in every 8,000 to 18,000

inpatient operations.—Gawande A A, Studdert D M,

Orav E J, et al. N Engl J Med.2003;348:229-235.

—Gonzales-Ojeda A, Rodrigues-Alcantar D A, Arenas-Marquez H,

et al. Hepatogastroenterology.1999:46:808-812.

In a study at the Mayo Clinicin Rochester, Minnesota, the ac-tual rate of retained items was 1 in 5,500 operations. Postopera-tive x-rays are routinely per-formed for open-cavity cases.

—Cima R R, Kollengode A, Garnatz, J et al. J Am Coll Surg.

2008;207:80-87.

The weak link in preventingretained foreign bodies is the de-ceptively correct count—72% to88% of retained items happen inoperations with “correct counts.”—Regenbogen S E, Greenberg C C,

Resch S C, et al. Surgery.2009;145:527-535.

(References 9-12)

Standard sponge countingalone is predicted to preventabout 82% of retained sponges,or a rate of 12 retained spongesper 100,000 operations.

With use of bar-codedsponges, the estimated rate of re-tained objects is 1 in 60,000 oper-ations, or 1.7 per 100,000.—Regenbogen S E, Greenberg C C,

Resch S C, et al. Surgery.2009;145:527-535.


Patient safety

been cleared by the Food and DrugAdministration.)

Empowering nursesOne benefit of the bar-coded

sponge system is that it has em-powered the nurses, Wienholzsays. When there is a count dis-crepancy, nurses can be more confi-dent that a missing sponge mightstill be in the patient.

A recent example was an early-morning case. At the end of the case,the bar-coding system showed amissing sponge. After a thorough in-spection by the staff of the backtable, floor, and garbage, the spongewas not recovered.

“They were pretty adamantwith the surgeon that it still had tobe in the patient,” Wienholz says.The surgeon called for an x-ray andconducted a manual wound explo-ration, locating the sponge.

Cohesive teamwork, aided bytechnology, averted a retainedsponge, she says.

Since introducing bar-codedsponges, Wienholz says OR nursesat UCSF have been able to predictwith 100% accuracy items thatwould have been retained.

She estimates the system’s costsat about $10 to $15 a case. “Thatmay seem like a lot if you do alarge number of cases, but if youcan avert one retained item, youpay for it,” she says.

The hanging sponge holder bagshave also been useful, she notes.“Now a relief nurse can walk into aroom, and it is clear where you arein your counts.”

Collaborate withphysicians

Collaborating with surgeonsand the radiology department iscrucial to a successful implementa-tion, Wienholz comments.

“If the physicians don’t see theimportance of counts and aren’t

Continued on page 11

SmartSponge System

ClearCount Medical Solutionswww.clearcount.com

The system, which combinessponge accounting and detection,consists of a bucket with scanner,RFID-tagged sponges, and scanningwand. Sponges are scanned in andout of the case. If there is a discrep-ancy, the patient is scanned with thewand to detect any remainingsponges. The system is cleared by theFood and Drug Administration(FDA).

Costs: ClearCount estimates thecost per case at $25 to $35, includinghardware and disposables. Thehardware is offered as a rental. Dis-posable costs include a sterile sheathfor the reusable wand plus theRFID-tagged sponges.

Installations: ClearCount an-nounced its first installation in June2009 at Memorial Sloan-KetteringCancer Center in New York City.

RF Surgical Detection System

RF Surgical Systems, Inc

www.rfsurg.com

The system has 3 components: Ahandheld scanning wand connectedto a console and micro radiofre-quency (RF) tags embedded ingauze, sponges, and towels. Whenthe wand is passed over a patient,an alarm signals the presence of anyretained RF-tagged item. The sys-tem can be used to locate missingsponges elsewhere in the OR. Thesystem was cleared by the FDAin2006.

Costs: Costs include $50 for thewand, now marketed for 24-houruse in each OR. On average, a wandis used for about 3 cases per day, the

company says. RF-tagged spongescost about 20 cents more than con-ventional sponges. Asterile wandsleeve is also needed. The consolesare provided on loan.

The company estimates the cost atabout $15 per case if averaged acrossall of a hospital’s surgical cases.

Installations: About 75.

Safety-Sponge System

SurgiCount Medical, Inc

www.surgicountmedical.com

The system includes bar-codedsponges and towels, a scanner, andsoftware for documenting countsand generating reports.

Sponges and towels have uniquebar codes. Sponges are scanned andrecorded during initial and finalcounts. The system was cleared bythe FDAin 2006.

Costs: The incremental cost perprocedure is estimated at $12 perprocedure by the company. Theonly incremental cost is the bar-coded sponges, according to Cardi-nal Health, the distributor. Thehardware (scanner/computer,mount for IV pole, charger, andextra battery) is available at nocharge.

Acost-effectiveness model devel-oped by Harvard researchers foundbar-coded sponges were the onlytechnology with a cost-per-eventprevented in a range acceptable tomost institutions (Regenbogen S E,Greenberg C C, Resch S C, et al.Surgery. 2009;145:527-35). Marketingmodels for the RF systems havebeen modified since the study wasconducted.

Installations: Number of installa-tions not disclosed.

Technologies for sponge accounting and detection


Patient safety

NoThing Left BehindSteps to prevent retained items

Surgeons1. Use only x-ray detect-

able sponges or towels.Don't alter them.

2. Perform a methodicalwound exam while thenurses perform theclosing count. Take a“pause for the gauze.”Call out, “All spongesare out.” Then ask forthe closing suture.

3. At the end of the casebefore leaving the OR,look at the hangingsponge holders and say,“Show me that all of thesponges are there.”Dictate, “A methodicalwound exploration wasperformed, and I sawthat all sponges wereaccounted for.”

Nurses1. In-count: Use a

standardized andtransparent process.Record the count for allpersonnel to see.

2. Closing count: Whilethe surgeon does thewound exam, perform afocused 2-person count,using hanging spongeholders to get thesponges in one place.Check back: “We thinkthe count is correct.”

3. Final count: Performedbefore the patient leavesthe OR. Verify that allsponges (used andunused) are in thehanging spongeholders.

Radiologists1. X-ray the complete

operative field withproper technique;consider oblique/lateralviews.

2. Know what is beinglooked for; eg, the kindof sponge, the size ofneedle.

3. Report the findingsdirectly to the surgeonof record.

Source: Verna C. Gibbs, MD.

NoThing Left Behind campaign

Sponge ACCOUNTing system

Checklist

Audit at the end of every case.

� All plastic bags in the OR used forsponge accounting are clear.

� Blue-backed sponge holders are on arack, mounted to an IV pole thatdoesn’t tip.

� Count is recorded in standardizedformat on dry erase board as a runningtotal.

� During in-count, the scrub personand circulating nurse “separate, see,and say” 10 sponges.

� Every closing count has a surgeonperform a methodical wound exam.

� Full sponge holder(s) (all sponges) atfinal count have a visual teamverification.

Source: NoThing Left Behind, VernaGibbs, MD. Used with permission.

Hanging spongeholders.


Patient safety

willing to allow the nurses to getthe technology up and running, thestaff will be forced to find short-cuts,” she says. “It really comesdown to the nursing staff feelingthey have a sense of ownership oftheir practice and the technology.”

Collaborating with the radiol-ogy department is also important.Because the bar-coding system canalert nurses to miscounts, intraop-erative x-rays to rule out a retaineditem may be more common.

Rolling out RF technologyThe ORs at the Hospital of the

University of Pennsylvania inPhiladelphia have been using the RFSurgical Detection System since 2007.The system consists of a handheldscanning wand and radiofrequency-tagged gauze, sponges, and towels.

The technology is an additionalpatient safety feature. Nursescount as usual. The wand is usedfor all open cavity cases or whenthere is a count discrepancy.

If a sponge is not detected in thebody cavity, the wand can beswept over the trash and linencarts, notes Marianne Saunders,RN, BSN, CNOR, nurse managerof perioperative services.

In one example, the wandhelped locate a sponge in an un-likely spot during an orthopediccase. Normally, wanding isn’t nec-essary during orthopedic cases, butthe staff nurse had counted multi-ple times and not found thesponge. As the wand passed overthe area, the system alarmed, andthe sponge was found under thebed in the foot pedal of a drill.

Dr Gibbs comments that sheviews the wand as an adjunct to themethodical wound exam, addingthat the “wand should be used bythe surgeon in all cases if you arenot going to use a standardizedmanual counting system.”

Working through theimplementation

The University of Pennsylvaniawas one of the first to implementthe RF Surgical Detection System.Initially, there were some frustra-tions, says Saunders, which sheand her team worked through withthe company’s engineers. At first,wands alarmed if they touchedmetal on the back table or got tooclose to staff members’ RF-taggedID badges. The engineers adjustedthe signal and replaced the con-soles that control the wands, whichfixed the problem.

Gary Blackbourn, RF Surgical’svice president for sales and mar-keting, explains that the RF tags onthe sponges and on ID badges emitsignals that are similar but not thesame. The problem was fixed bytightening the signal in the RF Sur-gical software. He says the com-pany has not had issues with theRF system reacting to ID badgesfor about 1 to 11⁄2 years.

The wand is now marketed for24-hour use. Saunders explainsthat when the staff turns on theconsole and opens the wand, theylabel the wand, and it is good for24 hours. The staff must be edu-cated not to unplug the console be-tween cases. If the console is un-plugged for more than 2 minutes,use of the wand is lost, and a newone must be opened.

Have an education plan Saunders says education was

also needed for the physicians onthe new RF system. According topolicy, wanding is performed foropen cavity cases or when there is acount discrepancy. Though wand-ing takes less than a minute, somephysicians perceive it as a delay.

Extensive education is neededbefore the system is implemented,Saunders advises.

“We rolled it out to everyone be-forehand,” she says. Stations wereset up so all personnel could par-ticipate in demos. “We did demosfor weeks.” In addition, mass e-mails were sent to attending physi-cians, fellows, and residents. Thechief of surgery sent a memo sup-porting the initiative, which wasalso supported by the senior ad-ministration. �

—Pat Patterson

The California violation reports wereposted September 3, 2009, by the Cali-fornia Department of Public Healthwebsite at www.cdph.ca.gov. Lookunder News Room.

ReferencesCima R R, Kollengode A, Garnatz J,

et al. Incidence and characteris-tics of potential and actual re-tained surgical object events insurgical patients. J Am Coll Surg.2008;207:80-87.

Gawande A A, Studdert D M, OravE J, et al. Risk factors for retainedinstruments and sponges aftersurgery. N Engl J Med.2003;348:229-235.

Gibbs V C, Coakley F D, Reines HD. Preventable errors in the op-erating room: Retained foreignbodies after surgery. CurrentProblems Surg. 2007;44:281-337.

Gonzales-Ojeda A, Rodrigues-Al-cantar D A, Arenas-Marquez H,et al. Retained surgical bodiesfollowing intra-abdominalsurgery. Hepatogastroenterology.1999;46:808-812.


“

“The real work is to change

behavior.

The Mayo Clinic in Rochester,Minnesota, added bar-codedsponge technology in Febru-

ary 2009 as part of a comprehen-sive 4-year effort to improve pre-vention of retained foreign objects(RFOs).

The Mayo Clinic in Rochesterhas 98 ORs, 3 obstetrical ORs, and8 labor and delivery birthingrooms in 2 hospitals and performsabout 50,000 procedures a year.The project was described in theJoint Commission Journal on Qualityand Patient Safety. The Clinic re-ported its data on retained objectsand near miss reports in the Journalof the American College of Surgeons(sidebars).

The result of the project was to

improve from an average of 1 re-tained object or near miss every 16days to an average of 1 every 69days, a level that had been main-tained for over 2 years. The Sigmaperformance level rose from 5.6 to6.0, and remains essentially un-changed. (A process is consideredto be at Six Sigma when there are3.4 defects per 1 million opportuni-ties.)

Careful planning neededAdding technology is a step

that must be carefully analyzedand planned, says Robert Cima,MD, MA, associate professor inthe Department of Surgery andvice chairman of quality andsafety.

“I would not even considerlooking at any technology for thisproblem without an assessment ofthe need in an individual operatingroom environment,” he told ORManager in an e-mail.

“We spent 3 years preparing ourstaff so they understood the issues,saw the value leadership placed on


A 4-year effort to prevent retained items

Patient safety

Retained items atthe Mayo Clinic

Reviewing reports of retainedobjects at their institution over 4years and 191,168 operations, re-searchers at the Mayo Clinic inRochester found:• 34 actual retained objects, a

rate of 1 in 5,500 operations.Of these, 23 (68%) weresponges.

• For 21 events (62%), the countwas recorded as correct.

• 59% of the retained objectswere found unexpectedlythrough the Clinic’s routineuse of postoperative x-rays—in all, the counts were re-ported as correct.

• None of the retained objectshappened during emergen-cies or high blood-loss proce-dures. Objects were retainedmost commonly in routineoperations.

• The most common contribut-ing factor was a breakdownin communication, such asfailing to communicate withother team members when anitem was placed in a bodycavity.

Source: Cima R R, Kollengode A,Garnatz J, et al. J Am Coll Surg.2008;207:80-87.

Phase 1: Defect analysis andpolicy review

Researchers analyzed all retainedobjects and near misses reportedover 4 years. Amajor finding—in62% of 34 retained-object events,counts at the end of the case wereconsidered correct. The most com-mon root cause was a communica-tion failure.

Amultidisciplinary team then re-viewed and revised all policies andprocedures for retained objects andcounting. Many policies hadchanged over time but had not beencompletely revised or reconciledwith other policies.

Phase 2: Awareness andcommunication

A communication and educationcampaign was conducted for allphysicians, nurses, and alliedhealth personnel. The primary goalwas to ensure all team membersunderstood the problem and the

need to improve communication. AConscientious Count Cam-

paign was conducted to educatenurses, surgical technologists, andsurgical assistants on proper count-ing and revised count policies.

Phase 3: Monitoring andcontrol

The Surgical Event Team re-sponds to any near miss or actualretained object. Within 12 to 24hours, the team meets with all ORpersonnel involved to debrief teammembers about the event.

This process does not replace aroot cause analysis nor seek to as-sign responsibility for the event. Thepurpose is to determine any poten-tial system weaknesses. Within 24 to48 hours, the team prepares a memoand shares it with all OR personnel.

Source: Cima R R, Kollengode A,Storsveen A A, et al. Jt Comm J QualPatient Saf. 2009;35:123-132.

Mayo Clinic’s project phases


this effort, and had engaged themin trying to improve performance.”

Why add technology? Traditionally, RFO prevention at

the Mayo Clinic in Rochester hasincluded manual counts as well asroutine screening x-rays for open-cavity cases. The x-rays are per-formed in dedicated imagingrooms after patients leave the OR.

X-rays do not take the place ofmanual counts, stresses CherylWeisbrod, RN, MS, nurse adminis-trator of surgical services, notingshe has fielded many questionsabout this.

The decision to add bar-codingtechnology was made for severalreasons. First, definitions of re-tained objects by the Joint Com-mission and State of Minnesotahave become more precise in re-cent years, Dr Cima notes. Underthese definitions, objects are con-sidered retained if not detected be-fore the incision is closed. If there isno wound being closed, the defin-ing point is when the proceduralteam withdraws from the patient.

“Clearly, our x-rays did notallow us to meet these definitions,”he said.

The problem of accountingThe second reason was that the

Clinic’s analysis showed 50% of itsretained objects were sponges.

“Our main problem was one of‘accounting,’” Dr Cima notes. Barcoding is an “accounting” technol-ogy. In addition, he said, bar cod-ing is an established technology, iswell understood by staff, andmade sense economically.

Patient safety

Every OR at theMayo Clinic inRochester has a

standardized whiteboard for recordingcounts plus a wall-

size poster that liststhe “red rules” for

counting.


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Even with bar coding, he noted,“We continue to obtain postop sur-vey films to make sure needles orinstruments are not in the patient,even though we would still con-sider them RFOs because theywould be found outside the OR.”

Adopting bar codingA key to implementing the bar-

coding system was to understandin detail how the system wouldwork in the OR. A perioperativenurse educator guided the process,walking through the steps with thestaff and gathering feedback.

The team learned, for example,that the bar-code scanner did notwork as well when it was held inthe hand as when it was left in itsholder on the IV pole. But nursessaid it was easier to use when held.

“The scanner is not held at thesame angle as when it is in theholder,” Weisbrod explains. As aresult, some staff thought the scan-ner didn’t work. The solution wasto leave the scanners in the hold-ers, at least until more experienceis gained.

Other key steps were to educatethe department’s 15 nurse man-agers and to develop a group of“super-users” who could mentorothers.

White boards, red rulesTo make sure counts are per-

formed in a standardized manner,the Mayo Clinic has adopted “redrules” and standardized whiteboards (illustrations, p 13).

Every OR has a wall-sizedposter with the “red rules” forcounts. Red rules are clear, simpledirectives intended to foster pa-tient safety that are supported bythe entire organization. Any devia-tion causes activity to cease untilthe situation is addressed.

The red rules now state that the

final count includes, in addition tothe usual steps, scanning out of allsponge material and closing of thebar-coding report.

Every OR has a standardizedwhite board for recording counts.

“We have had erasable boardsfor years, but we found differentpeople wrote the information indifferent ways,” Weisbrod notes.The boards make the count visibleto the entire team.

“Before the end of the proce-dure, everyone looks at the whiteboard and says, ‘Are the countscorrect?’” she says.

In addition to sponge, needle,and instrument counts, the whiteboards have space to record tuckeditems. If a tucked item has not beenerased and is not accounted for, theteam knows to conduct a woundexploration and possibly have anx-ray taken.

An ongoing effortOR personnel are updated regu-

larly on how the surgical service isperforming on quality measures,including preventing retained ob-jects. An analyst collects data dailyon these and other measures,which are reported on controlcharts posted throughout the de-partment and on a surgical servicesscorecard.

The staff is encouraged to reportany concern or near miss to thesurgical services leadership. A Sur-gical Event Team reviews these re-ports and debriefs team membersinvolved. The process does not

take the place of root cause analy-sis nor does it seek to place respon-sibility. The focus is on what can belearned to improve the process.

But regardless of the technologyand other interventions, Weisbrodsays, “it comes down to the factthat we are human beings, and weneed to talk to each other. I havebeen in the OR a long time, and weused to have more time to talkwith the surgeons and residents.Now, with more technology tomanage, there seems to be lesstime for those face-to-face discus-sions.”

The ORs are introducing brief-ings and debriefings to encouragecommunication. The departmenthas provided education in CrucialConversations, a program by Vi-talSmarts (www.vitalsmarts.com)that teaches people how to bringup and discuss difficult issues ef-fectively.

“There are events that willoccur,” she says. “We tell the staff,‘Be respectful. But don’t be afraidto speak up.’ We are here. We willsupport you.” �

—Pat Patterson


Patient safety


“

“Every OR

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OR business manager gains ground

The OR business manager po-sition has gained ground inthe past 5 years. Well over

one-third (37%) of ORs respondingto the OR Manager Salary/Careersurvey have business managers,compared with 24% in 2004. Forthe second year, the survey in-cluded specific questions about theOR business manager.

The OR Manager Salary/CareerSurvey was mailed in April 2009 to800 OR Manager subscribers whoare directors or managers of hospi-tal ORs; 323 were returned for a re-sponse rate of 40%.

Over half (54%) of teachinghospitals and a third (31%) ofcommunity hospitals have ORbusiness managers. In contrast, 5years ago only 44% of teaching in-stitutions and 18% of communityhospitals had the position.

The average salary is $78,600,up from $73,000 in 2008, the firstyear this question was asked.Salaries range from more than$100,000 to less than $60,000.Salary information was providedby 71 of the 109 respondents whohave an OR business manager.

Reporting structureMost business managers (70%)

report to the OR director or direc-tor of surgical services, with theremainder reporting to a senioradministrator such as the nurseexecutive or chief financial officer.

More than half (51%) havestaffs of 4 or more direct reports;19% do not have direct reports.

ResponsibilitiesThe 5 leading areas of responsi-

bility are financial analysis and

reporting, the annual budget,billing and reimbursement, valueanalysis/product selection, andmaterials management.

QualificationsMore respondents this year

(78%) say a specific degree is re-quired for the OR business man-ager position, compared with 73%in 2008. For those that require a de-

Salary/Career Survey


No(n = 190)

64%

Yes(n = 109)

37% OR director 70%Chief financial officer 6%Nursing executive 6%Chief operating officer 6%Other (such as VP) 12%

Does your OR have a business manager?

To whom does the business manager report?(n = 109)

By number of ORs

1-4 5-9 10+(n=5) (n=17) (n=84)

By facility type

Community Teaching(n=66) (n=39)31% 54%

8% 21% 56%

$100K 11%

$90K-$99,999 11%

$80K-$89,999 12%

$70K-$79,999 16%

$60K-$69,999 13%

<$60K 8%

Don't know 29%

OR businessmanager salaries(n = 71)

Mean = $78,600 Median = $75,000

Is a specific degree required for the ORbusiness manager?

No(n = 24)

22%

Yes (n = 84)

78%

Bachelor’sMaster’s (any)MBA

Degree required

50%19%31%

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*Based on calculation of 10.9 minutes per case at Beaufort Memorial Hospital. Individual results may vary.© 2009 CareFusion Corporation or one of its subsidiaries. All rights reserved. Pyxis is a registered trademark of CareFusion Corporation or one of its subsidiaries. PS1027

carefusion.com/OR


gree, the split is 50-50 between thosethat call for a bachelor’s or a mas-ter’s degree. Most that specify amaster’s degree, 26 out of 42, re-quire a master’s in business admin-istration. Perhaps not surprisingly,teaching hospitals (87%) are morelikely to require a specific degreethan community hospitals (70%).

One-third (33%) require thebusiness manager to have a clinicalbackground, similar to 2008. Com-munity hospitals are more likely torequire a clinical background forbusiness managers than teachinginstitutions (41% vs 21%). �

The OR Manager Salary/Career Surveyresults on staffing were in the September2009 OR Manager. Results on salariesand benefits were in the October issue.

Salary/Career Survey


Financial analysis/reporting 92%

Annual budget 74%

Billing/reimbursement 71%

Value analysis/product selection process 60%

Materials management 57%

Purchasing 52%

Surgical information system 44%

Strategic planning 42%

OR scheduling 35%

Quality improvement 17%

Other 6%

What are the OR businessmanager’s responsibilities?(n = 108)

Is a clinical backgroundrequired for the OR business manager position?

No (n = 72)

67%

Yes (n = 36)

33%

How many direct reportsdoes the OR businessmanager supervise?

None (n = 20)

19%

1-3 (n = 32)

30%

4+(n = 55 )

51%

Thank youOR Manager thanks the respondents

who took time to complete this year’ssurvey. We appreciate your part in

gathering this information, which willbe useful to your colleagues around

the country.

Failure to rescue drives postoperative mortality

Anew study debunks as-sumptions about the role ofcomplications in distin-

guishing low- and high-mortalityhospitals. The report in the Oct 1New England Journal of Medicine con-firms that serious complications arecommon after major surgery—about 1 in 6 patients—but the studyshows failure to rescue is what dri-ves hospital mortality.

Heading off complicationsLow-mortality hospitals have

teams with the ability to rescue pa-tients by recognizing and heading offpotentially catastrophic complica-tions such as deep wound infections,pneumonia, kidney failure, blood

clots, and strokes. Despite similarpatterns of complications, patients athigh-mortality hospitals are nearlytwice as likely to die after developinga serious postop complication.

“The general assumption hasbeen that high-mortality hospitalssimply have higher complicationrates. We were quite surprised tofind that’s not true,” says study au-thor John D. Birkmeyer, MD, of theUniversity of Michigan, Ann Arbor.

The study used data from 84,730patients having general and vascu-lar surgery at 186 hospitals partici-pating in the American College ofSurgeons National Surgical QualityImprovement Program (NSQIP).

The hospitals’ mortality rate var-

ied dramatically from 3.5% to 6.9%.But there was not much differencein the complication rates, 18.2% ver-sus 16.2%.

Dr Birkmeyer says the findingsgive a better sense of what to lookfor in reducing mortality rates fromsurgery.

“Rather than focusing on whatthe surgeon does in the operatingroom, we need to focus on what’shappening on the wards and in theintensive care unit afterward.”�

ReferenceGhaferi AA, Birkmeyer J D, Dimick J

B. Variation in hospital mortalityassociated with inpatient surgery.N Engl J Med. 2009;361:1368-1375.


Tackling an outbreak of MRSA SSIs

In late 2007 and early 2008, anArizona hospital saw an alarm-ing increase in surgical site in-

fections (SSI) with methicillin-resis-tant Staphylococcus aureus (MRSA).

For the first quarter in 2008, theinfection rate for total hip replace-ments and revisions averaged3.73%, well above the national av-erage of 1.6%, with most involvingMRSA. Some MRSA infections hadalso occurred after total knee pro-cedures, cholecystectomies, andhernia repairs with mesh.

A multidisciplinary team at thehospital, Banner Baywood MedicalCenter in Mesa, which has 10 ORs,began a top-to-bottom review ofthe OR environment and practices.

By the end of October 2008,MRSA SSIs fell to zero, and nonewere reported through early May2009.

MRSA can be devastating. Pa-tients who develop an MRSA SSIhave a 3.4 times higher risk ofdeath than patients with methi-cillin-susceptible Staph aureus, andtheir median hospital costs are al-most twice as high, according toEngemann, et al.

These are steps the hospital tookto reach zero for MRSA SSIs. TwoOR issues the team found neededparticular attention—OR ventila-tion (positive pressure) and termi-nal cleaning.

Team goes to workIn May 2008, the infection pre-

ventionist, Julie Peters, RN, gath-ered a multidisciplinary team tobegin a review and make recom-mendations. Included were repre-sentatives from the OR as well asinfection control, sterile processing,and quality management. Theyused as their guide the Centers forDisease Control and Prevention

Guideline for Prevention of Surgi-cal Site Infection, 1999.

The group reviewed steriliza-tion practices. Flash sterilizationwas already minimal. Among stepsthey took:• All prevacuum cycles were stan-

dardized, and 1 minute wasadded to drying time.

• Autoclave settings were set so thestaff cannot change them.

• The team changed to thicker ster-ilization wrap, sent letters to ven-dors reminding them to checkand replace trays with spurs andsharp edges, and placed plastictrays under consigned orthopedictrays to reduce tearing of wrap.

• A new process was employedfor cleaning all instrument con-tainers.Hand hygiene compliance in pe-

rioperative services averaged 75%,higher than in other units. To aidcompliance with contact precau-tions, the hospital uses color codingto identify patients who are andwho are not on contact precautions.

Informing the surgeonsPeters presented information on

the outbreak to the Surgery Com-mittee, which discussed practicessuch as ensuring that the antibioticfor total knee procedures wasgiven before the tourniquet wasapplied and the antibiotic was ad-ministered within 1 hour of inci-sion for all cases.

Compliance with the antibioticmeasures from the Surgical CareImprovement Project (SCIP) fortotal joint procedures in the secondhalf of 2008 was 94% or above.These include giving the antibioticon time and selecting the right an-tibiotic. Appropriate hair removalwas at 100% overall.

The surgeons discussed whetherto introduce active surveillancetesting for patients at high risk forMRSA, but have not gone aheadwith that at present.

The effectiveness of active sur-veillance testing in preventingMRSA transmission is controver-sial, and optimal strategies for test-ing have not been resolved, accord-ing to a review of strategies for pre-venting MRSA transmission byCalfee and colleagues, part of thecompendium on preventing healthcare-associated infections (HAI)


“

“Terminal cleaning wasn’t

up to par.

Compendium has advice oninfection

A comprehensive review ofstrategies for preventing healthcare-associated infection is avail-able from the Society for Health-care Epidemiology of America.Included are strategies for:• surgical site infection• central line-associated blood-

stream infection• catheter-associated urinary

tract infection• ventilator-associated pneu-

monia• Clostridium difficile• Methicillin-resistant Staphylo-

coccus aureus.— www.shea-online.org/about/

compendium.cfm

Infection control


Infection control

from the Society for Healthcare Epi-demiology of America (SHEA) andother organizations (sidebar, p 21).

Education reinforcedThe team began reinforcing edu-

cation for the staff on sterile tech-nique and the SCIP measures. A re-view was conducted for the OR as-sistants and environmental ser-vices staff on decontamination andsterilization techniques. The needto control traffic in and out of theORs was reinforced. ORs whereimplants are performed have signson the doors instructing personnelto enter only through the sterilecore.

A surprise discovery Though reports showed all OR

ventilation parameters were withinguidelines, the team discovered toits surprise that 5 of the 10 ORswere actually under negative airpressure rather than positive pres-sure as recommended, says ChrisHalowell, RN, MS-HSA, CNOR,director of perioperative services.In a positive pressure room, airflows outward to the corridor,sweeping out contaminants. Undernegative pressure, air currents flowinto the room.

The discovery was made on aweekend when the team came in toinvestigate an unrelated incident.A technician performed a “tissuetest,” using a facial tissue to see theflow of air currents in the ORs andfound air was actually flowing into5 rooms.

“I didn’t believe him at first. But

he showed me he was correct,”Halowell says.

The team immediately con-tacted the facilities department tomake sure OR ventilation wasbrought within the correct parame-ters. (A table with the recom-mended parameters for OR heat-ing, ventilation, and air condition-ing is in the AORN 2009 Periopera-tive Standards and RecommendedPractices, p 421.)

Terminal cleaning gapsThe team also learned terminal

cleaning in the ORs wasn’t up topar. Environmental cleaning is im-portant because patients infectedor colonized with MRSA contami-nate their environment, which canin turn contaminate health careworkers’ hands, clothing, andequipment.

Hip/hip revision infection rateMarch 2007-2009 YTD

Source: Banner Baywood Medical Center.



Infection control

When Georgie Elias, RN, BS,CNOR, CPN, senior clinical man-ager for surgical services, and an-other clinical manager spent aweek each with the terminal clean-ers, they found lapses.

“We found they weren’t makinga connection between invisiblebugs and the dust they could see,”Halowell notes.

Some creative ways were usedto reinforce the cleaners’ education.Elias seeded an area with a harm-less powder called Go Germ,which is invisible under normalconditions but glows under a blacklight (www.glogerm.com).

She had the cleaners performtheir routine cleaning and used theblack light to check their work.

As a further check, Elias used aluminometer, a device that detectslow levels of light from ATP(adenosine triphosphate) in thecells of biological material to checkon the effectiveness of cleaning.

“We found they still were miss-ing important parts of the roomlike the high-touch surfaces,” Eliassays.

When the cleaners’ performancedidn’t improve after these efforts,they were let go.

Preoperative wash forpatients

As an additional measure, surgi-cal patients are now given a bottleof 4% chlorhexidine gluconate, orCHG (Hibiclens), at their preopera-tive appointment and instructed toshower with it the day of surgery.Also, in the preoperative area, pa-tients’ surgical areas are cleanedwith 2% CHG wipes. CHG pro-vides persistent activity against mi-croorganisms. For the skin prep,most of the orthopedic surgeonsprefer an iodophor, Halowellnotes.

Preoperative bathing with CHGis considered an unresolved issue

in the strategies to prevent surgicalsite infections by Anderson andcolleagues, part of the HAI com-pendium. Though showering withCHG before surgery has beenshown to reduce bacterial coloniza-tion of the skin, studies have notshown clear evidence of a benefit,the article notes. AORN recom-mends that patients having Class 1surgical procedures below the chinhave 2 preoperative showers withCHG when appropriate.

Reinforcing sterileconscience

The team also looked for waysto reinforce aseptic technique andsterile conscience.

“Everyone is trained in that. ButI think as time goes on, people startgetting lax,” Elias says.

An in-service on the study Si-lence Kills provided an eye-open-ing reminder. The study, releasedin 2005, found fewer than 10% ofhealth care workers speak upwhen they see a colleague breakrules, make mistakes, or appearclinically incompetent (www.si-lencekills.com).

Banner Baywood had alreadyintroduced Crucial Conversations,a training program that teachesskills for addressing difficult issueswith colleagues (www.vitals-marts.com).

The training is also being pro-vided to the nonclinical staff.Halowell has found it is helpful towork with them in small groups.

“We have said, ‘It is OK to call

the nurses and doctors on theirpractice if you think it is harmingyour patient,’” Halowell says. “Thepatient is the center of focus.”

Team SafeA hospitalwide program called

Team Safe is being introduced todevelop a culture of safety and ac-countability.

“We are trying to create ac-countability so a person is notafraid to confront a coworker in theOR or anywhere,” says Peters. Per-sonnel learn to watch for andspeak up about safety lapses, suchas medication that is lying aroundor failure to observe hand hygieneor isolation precautions.

Halowell says that as a result ofthe training, she observes morestaff intervening when they see alapse, and she believes most staffwould now speak up about a prac-tice breach.

Targeting zeroHalowell admits to feeling “a

little complacent” prior to 2008.She says the effort to address theoutbreak raised awareness at alllevels of the organization.

“Now I’ve learned you don’ttake a piece of paper for granted.You have to do your own testing,”she says, referring to the OR venti-lation reports.

She adds that the experienceand Crucial Conversations traininghelped get the staff involved andfueled the department’s sharedleadership team.

“It’s been a team effort to fix it,”she says.

For Peters, the situation rein-forced the value of the CDC SSIguideline.

“Now I think targeting zero ispossible,” she says. “It’s like adiet—there is no immediate fix. Itrequires a change in habits that


“

“Staff learned aboutspeaking up.


Six hospitals in Indiana andAlabama agreed to pay thegovernment more than $8

million to settle allegations thatthey submitted false claims toMedicare, the US Department ofJustice announced September 29,2009.

The settlements resolve allega-tions that from 2002 to 2008, thehospitals overbilled Medicare forkyphoplasty, a minimally invasiveprocedure used to treat spinal frac-tures due to osteoporosis.

The government contends thehospitals performed the proce-dure on an inpatient basis to in-crease their Medicare billingseven though kyphoplasty inmany cases can be performedsafely as outpatient surgery.

The Indiana hospitals include StFrancis Hospital in Beech Grove($3.2 million), Deaconess Hospitalin Evansville ($2.1 million), and StJohn’s Health System in Anderson($826,000).

The Alabama hospitals are StVincent’s East Hospital ($1.5 mil-lion) and St Vincent’s BirminghamHospital ($423,000), both in Birm-ingham, and Providence Hospitalin Mobile ($382,000).

Some 100 hospitals are said tobe under investigation.

The settlements follow the gov-ernment’s $2.3 million settlementwith 3 Minnesota hospitals in May2009 for allegedly fraudulentkyphoplasty claims.

In 2008, the government reacheda $75 million settlement withMedtronic Spine LLC, which nowowns Kyphon, the company thatdeveloped the procedure. Thecompany did not admit wrong-doing.

St Francis said in a statementthat it cooperated fully with thegovernment. It said the focus of theinvestigation was on “the lack of

documentation to support thetreatment in an inpatient setting.”

St Vincent’s Health System alsosaid it had cooperated in the inves-tigation, admitted no liability, andsettled to avoid further litigationcosts. It said the investigation fo-cused on documentation, and“there were no concerns about themedical necessity of the kypho-plasty itself for any patients.”

St John’s Health System issued asimilar statement.

Whistleblower lawsuitThe settlements stem from a

whistleblower lawsuit filed in 2006by 2 former Kyphon employees,Craig Patrick, a former reimburse-ment manager, and Charles M.Bates, a former regional sales man-ager.

The suit alleged that Kyphonconducted a fraudulent marketingcampaign that induced hospitals tobill Medicare for kyphoplasty as aninpatient procedure.

Billings for unnecessary inpa-tient admissions are consideredfalse claims under the False ClaimsAct.

Among allegations were thatKyphon representatives met withhospital personnel to explain howto code and bill charges to ensurepayment under the DRGs.

Court documents also said salesreps would be present in the ORduring kyphoplasty and weretaught how to prompt staff andphysicians to order inpatient ad-missions (July 2009 OR Manager).

The whistleblowers will receiveabout $1.4 million as their share ofthe settlements. �

Six hospitals settle with feds overMedicare claims for kyphoplasty

Infection control

must be followed for life. You haveto tighten up on the basics.”�

—Pat Patterson

ReferencesAnderson D J, Kaye K S, Classen D,

et al. Strategies to prevent surgi-cal site infections in acute carehospitals. Infect Control Hosp Epi-demiol. 2008;29:S51-S61.www.shea-online.org/about/compendium.cfm

AORN. Recommended practices forpreoperative patient skin anti-sepsis. Perioperative Standards andRecommended Practices. Denver:AORN, 2009.

AORN. Recommended practices fora safe environment of care. Peri-operative Standards and Recom-mended Practices. Denver: AORN,2009. Recommended HVAC set-tings, p 421.

Calfee D A, Salgado C D, Classen,D, et al. Strategies to preventtransmission of methicillin-resis-tant Staphylococcus aureus inacute care hospitals. Infec ControlHosp Epidemiol. 2008;29:S62-S80.www.shea-online.org/about/compendium.cfm

Centers for Disease Control andPrevention. Guideline for preven-tion of surgical site infection, 1999.www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html

Engemann J, Carmeli Y, Cosgrove S,et al. Adverse clinical and eco-nomic outcomes attributable tomethicillin resistance among pa-tients with Staphyloccus aureussurgical site infections. Clin InfecDis. 2003;36:592-598.

Facilities Guidelines Institute.Guidelines for Design and Con-struction of Health Care Facilities.Washington, DC: American Insti-tute of Architects, 2006. Includesventilation guidelines.www.fgiguidelines.org


Check our website for the latest news, meetingannouncements, and other

practical help. www.ormanager.com


Avoiding inpatient-only claims pitfalls

OR business management

Understanding how Medicarepays for inpatient and out-patient surgery is critical to

your hospital’s revenue. Medicarestipulates that certain procedureswill be paid only if performed onan inpatient basis. How can youavoid pitfalls of billing for these in-patient-only procedures?

OR Manager asked Keith Siddel,MBA, an expert on health carebusiness operations, to respond tofrequent questions. He is CEO ofHRM Consulting, Creede, Col-orado.

QWhat qualifies as aninpatient-only procedure?

How should we handle a changefrom an outpatient to aninpatient procedure that occursduring surgery?

Siddel: To explain the back-ground on this issue, Medicaredesignates that for safety reasons,particular procedures should beperformed only on an inpatientbasis. The thinking is that it is notsafe to send patients home thesame day.

For procedures on the inpatient-only list, Medicare says, “If youdon’t do this as an inpatient proce-dure, we won’t pay.” Not only doyou not get paid for the surgerybut also for any other services asso-ciated with that episode of care,such as the IV line inserted beforethe patient went to the OR.

The inpatient-only list is up-dated every year by the Centers forMedicare and Medicaid Services(CMS) as part of the Medicare Out-patient Prospective Payment Sys-tem (OPPS) rule. This year, the pro-posed OPPS rule was releasedearly on July 1, 2009. A final rule isexpected this fall. The rule is effec-tive for discharges taking place

after January 1, 2010. The HCPCScodes paid only as inpatient proce-dures are found in Addendum E.

In the final rule, CMS will list allof the comments it received anddiscuss its decisions for updatingthe inpatient-only list. Once thefinal rule is published, all of the in-patient-only procedures must bedone on an inpatient basis.

Be alert to procedurechanges

Most hospitals do a good job ofscreening for these inpatient-onlyprocedures. For example, thescheduling software usually notesif a patient is scheduled for such aprocedure.

If a hospital loses reimburse-ment for this reason, 90% of thetime it is because the physicianmakes a decision that changes theoriginal procedure. For example,the physician might say, “Thislooks more complicated than Ithought. Let’s expand it.” Thatmay move the case into an inpa-tient-only mode.

When that happens, someone inthe OR needs to alert the appropri-ate person and say, “By the way,we not only did the scheduled pro-cedure. We also did B or C proce-dure.” Then someone needs tocheck the procedure against the in-patient-only list. If the procedure isinpatient only, a manager needs togo to the physician and say, “Thisis inpatient only. Will you write anorder to admit this patientovernight?”

Avoiding denialsThe real problem occurs when

the change isn’t caught. The pa-tient remains an outpatient andgoes home the same day ratherthan being admitted. The record iscoded and billed, and the claim is

denied. There is really not an ap-peal process, even if the procedurewas done as an emergency.

CMS has declined to authorizean appeal process or to provide amodifier to address an unsched-uled inpatient-only procedure.CMS has also said no to a processthat would at least pay a hospitalfor ancillary services associatedwith an unscheduled inpatient-only case. This is what CMS said inthe final 2009 OPPS rule: “We un-derstand hospitals’ dilemma whena decision is made intraoperativelyto perform an unscheduled proce-dure. However, we continue to be-lieve it is important for hospitals toeducate physicians on Medicareservices paid under the outpatientprospective payments system toavoid inadvertently providing ser-vices in a hospital setting thatwould be paid only during an in-patient stay, because we believethat the hospital outpatient depart-ment is not an appropriate site ofservice for these procedures.”

Basically, CMS said it is the hos-pital’s problem, and the hospitalhas to educate the physicians. �

The Medicare 2010 OPPS final rulewill be posted atwww.cms.hhs.gov/center/hospital.asp

Have a question on the OR revenue

cycle?

Keith Siddel will respond toquestions in a regular

column. Send your questionsto Pat Patterson, Editor, at

[email protected] can also reach Siddel at

[email protected].


ASCs weigh impact of Medicare pay

Is it time to stop performingcolonoscopies and go fullsteam ahead with knee sur-

gery? Maybe. According to theproposed Medicare OutpatientProspective Payment System(OPPS) rule released July 1, 2009,colonoscopy reimbursement ratesfor ambulatory surgery centers(ASCs) will decline by 5.6% in2010, compared with an increaseof 15% for knee arthroscopy withrepair of medial meniscus.

On the other hand, Medicare isproposing to reimburse 2 addi-tional gastrointestinal proceduresnext year, providing an increase inpotential business at some surgerycenters.

Expect final rule inNovember

That is a small example of factorsASCs must weigh as they adjust theirstrategic planning. It is not all aboutMedicare payments, of course; thelocal market, staff specialties andpreferences, and demographic pro-jections play a role as well.

For ASCs serving a large elderly

patient population, however, it willpay to keep an eye on the trends asthe Centers for Medicare and Med-icaid Services (CMS) issues its finalrule in November. The rule will beeffective January 1, 2010.

“You will need to review pay-ment changes at the procedurelevel to determine the impact ofthe proposed changes on your par-ticular ASC,” the AmbulatorySurgery Center Association re-minds members in its summary ofthe proposed 2010 rates.

As an example, CMS plans toadd 28 procedures to the list ofthose it will reimburse ASCs fornext year. They include surgery torepair the tibia, at $1,775.48; repair-

ing arterial or venous blockage,$1,990.24; and partial thyroid exci-sion, at $1,926.01. For the completelist, visit the ASC Association’swebsite www.ascassociation.org.

‘Aligning payments’On the down side, reimburse-

ment for some of the most commonoutpatient procedures will decrease.The most dramatic example is injec-tion of anesthesia into the spine tomanage back pain (HCPCS code64476), for which the proposed pay-ment would decrease by 25.6%.

The rule covers both ASCs andhospital outpatient departments(HOPDs) but at different paymentlevels.

According to CMS, the aim of the4-year transition period to the newASC payment system, of which2010 will be the third year, is to alignrates for similar services for bothtypes of outpatient facilities.

However, rates will be alignedat different levels, with ASCs get-ting a smaller share because of eco-nomic advantages ASCs are per-ceived to enjoy.

Lee Anne Blackwell, RN, BSN, EMBA,CNORDirector, clinical resources and educa-tion, Surgical Care Affiliates,Birmingham, Alabama

Nancy Burden, RN, MS, CAPA, CPANDirector, Ambulatory Surgery, BayCareHealth System, Clearwater, Florida

Lisa Cooper, RN, BSN, BA, CNORExecutive director, El Camino SurgeryCenter, Mountain View, California

Rebecca Craig, RN, BA, CNOR, CASCCEO, Harmony Surgery Center, FortCollins, Colorado and MCR Surgery Cen-ter, Loveland, Colorado

Stephanie Ellis, RN, CPCEllis Medical Consulting, IncBrentwood, Tennessee

Rosemary Lambie, RN, MEd, CNORNurse administrator, SurgiCenter of Balti-more, Owings Mills, Maryland

LeeAnn PuckettMaterials manager, Evansville SurgeryCenter, Evansville, Indiana

Donna DeFazio Quinn, RN, BSN, MBA,CPAN, CAPADirector, Orthopaedic Surgery CenterConcord, New Hampshire

Ambulatory Surgery Advisory Board

“

“Trend is toward lower

payments.


A complex system of weightsand legislative compromises hasresulted in proposed rates that giveASCs on average 57.7% of HOPDpayments for similar procedures,plus a hard-won inflation updateof 0.6%. HOPDs would receive2.1% toward inflation under theproposal. Under an earlier versionof the rule, ASCs would have re-ceived no update for inflation.

According to CMS projections,total Medicare payments toHOPDs in 2010 will be $31.5 bil-lion, while ASCs will receive just$3.4 billion. CMS estimates about5,000 ASCs participate in Medicare.

An unfair system?Is the new system unfair? ASCs

maintain it is. In a recent presenta-tion, ASC Association PresidentKathy Bryant asked, “How do westop the bleeding?” She called onCongress at least to equalize infla-tion updates for ASCs and HOPDs.

Caryl Serbin, RN, BSN, LHRM,explains that based on a Govern-ment Accountability Office (GAO)review, the typical ASC cost for aprocedure was 84% of that of anHOPD. Despite that, CMS origi-nally planned to give ASCs 75% ofthe HOPD rates. In 2008, that wasreduced to 65%. In 2009, the ratedeclined again to 59%, and in 2010,it is due to drop to 57.7%.

“If it costs ASCs 84% of what itcosts HOPDs to perform a proce-dure,” Serbin says, “and ASCs getreimbursed 57.7% of what HOPDsget reimbursed, it sounds like theASCs are losing money.”

Serbin is the owner of SerbinSurgery Center Billing, Fort Myers,Florida, a provider of outsourcedcoding, claims submission, andcollections services.

The device factorIn one way, the Medicare pay-

ment rules recognize that ASCs,like their hospital counterparts,have become increasingly depen-dent on expensive, high-tech prod-ucts they must purchase to treatpatients, from orthopedic implantsto laparoscopic instruments to car-diac catheters.

So while the new ASC paymentrate for a service is a fraction of theHOPD rate, when devices repre-sent more than 50% of the cost of aprocedure, payments are equal.

The bad news is, once again, mostpayments are decreasing. A big ex-

ception is cardiology, where insertinga pacemaker lead will bring in morethan 50% more (chart).

Specific rates could change in thefinal rule, but the trend representslittle change from previous yearsand is unlikely to vary drastically.

In addition, though CMS plansto increase by 28 the number ofprocedures it will pay ASCs for, italso proposed to designate 6 otherprocedures as payable only at thelower rate applied to office-basedprocedures.

Another indication of the trendtoward lower payments is the factthat the highest-volume ASC pro-cedures will be paid less in the fu-ture. After-cataract laser surgerywill drop by 8.6%; upper GI en-doscopy with biopsy will declineby 7%.

Tighter constraintsAccording to Serbin, overall

ASCs are facing tighter economicconstraints. This is true, she says,

AmbulatorySurgery Centers

Proposed ASC payment changes for device-intensive procedures

HCPCS Proposed 2009 % code Name 2010 rate rate change

24361 Reconstruct elbow joint 6,079.17 6,085.62 -0.10%

24363 Replace elbow joint 6,145.30 6,221.16 -1.20%

24366 Reconstruct head of radius 6,079.17 6,085.62 -0.10%

25446 Wrist replacement 6,145.30 6,221.16 -1.20%

27446 Revision of knee joint 6,401.02 10,921.17 -41.40%

29881 Knee arthroscopy 1,036.94 901.24 15.10%

33206 Insert cardiac pacemaker 6,939.30 6,938.76 0.00%

33224 Insert pacing lead and connect 12,694.82 8,123.29 56.30%

62361 Implant spine infusion pump 11,849.33 10,941.40 8.30%

64476 Paravertebral injection 158.13 212.55 -25.60%

Source: Centers for Medicare and Medicaid Services.

“

“Pain management

and GI are vulnerable.


First in a series on quality improve-ment for ambulatory surgery centers.

Ambulatory surgery centers(ASC) have a new sourcefor benchmarking data.

The national ASC Quality Collabo-ration is now posting quarterlydata on 6 quality and safety mea-sures (sidebar). The measures,which are in the public domain,were developed by ASC leadersspecifically for surgery centers.

“These are consensus standardsdeveloped by the ASC Quality Col-laboration and endorsed by the Na-tional Quality Forum,” explainsDonna Slosburg, RN, BSN, LHRM,CASC, the Collaboration’s executivedirector. NQF, a nonprofit organiza-tion, endorses consensus health carequality measures. The data areposted at www.ascquality.org.

Depending on the measure, thedata represent from 423 to 1,294surgical facilities and from 433,000to 1.5 million patient admissions.The latest results include figuresfrom the ASC Association’s Out-comes Monitoring Project, withabout 600 ASCs enrolled.

The measures with the mostdata to date are patient falls in theASC and patient burns. There isless data on the 2 process mea-sures, on-time administration ofprophylactic antibiotics and appro-priate hair removal.

Quality reportingQuality measurement is becom-

ing increasingly important to en-sure quality as well as to meet reg-ulatory requirements.

The Centers for Medicare and

Medicaid Services (CMS) refers to5 of the ASC Quality Collaborationmeasures as examples of onessurgery centers can use in its inter-pretative guidelines for state sur-veyors. The interpretive guidelinessupport the revised Medicare Con-ditions for Coverage (CfCs), whichrequire ASCs to have a quality as-sessment and performance im-provement (QAPI) program. Ac-cording to the interpretive guide-lines, ASCs may choose to usethese measures but are also free touse different measures as long asthey meet regulatory criteria.

How can ASCs use the data?ASCs can use the ASC Quality

Collaboration’s data to comparetheir own results with other facili-ties across the country, Slosburgsuggests.

For example, for patient burns,an ASC could compare its experi-ence to the national rate. If that

ASC’s rate of burns is significantlyhigher, “I would look to see if therewere any trends. Then I would seewhat changes are needed to correctthat,” she advises.

There are a couple of caveatsabout using the data.

First, ASCs need to make surethey are “comparing apples to ap-ples” by using the same defini-tions, Slosburg notes. (The defini-tions are on the Collaboration’swebsite.)

For instance, the Collaborationdefines patient falls as those thatoccur “within the confines of theASC.” To compare its results, anASC would need to use the samedefinition; that is, exclude falls thathappen outside the ASC, such as inthe parking lot or after the patientgoes home.

In a second caveat, 4 of the mea-sures are reported as the rate per1,000 patient admissions. An “admis-


ASCs can benchmark quality data


ASC quality measuresMeasures endorsed by the National Quality Forum. Data for second quarter of 2009.

RatePatient falls in the ASC 0.183 per 1,000 admissions

Patient burns 0.042 per 1,000 admissions

Hospital transfer/admission 0.997 per 1,000 admissions

Wrong site, side, patient, 0.032 per 1,000 admissionsprocedure, implant

Prophylactic antibiotic 96%given on time

Appropriate surgical site 98%hair removal

Source: ASC Quality Collaboration. www.ascquality.org



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1. Publication title: OR Manager

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9. Full names and complete mailing addresses of publisher,editor, and managing editor: Publisher, Elinor S. Schrader, 1807Second St., #61, Santa Fe, NM 87505-3510; Editor, PatriciaPatterson, 3056 S Robin Way, Denver, CO 80222; managingeditor, none.

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Signed: Elinor S. Schrader. Date: 9/24/09


sion” is defined as a patient who hascompleted registration to the facility.

ASCs often use a percentage tomeasure their rates. To compare tothe Collaboration data, they wouldneed to divide by 10. For example,taking the patient fall rate of 0.183per 1,000 admissions and dividingby 10, the rate would be 0.0183 fallsper 100 patient admissions, orabout 2/100th of 1%.

Many ASCs track their data on aquarterly basis. Now they can use

the Collaboration’s data for com-parison, Slosburg notes.

Medicare’s qualityreporting plans

Surgery centers have been ex-pecting Medicare to start requiringASCs to report quality data, as hos-pitals now do. But CMS proposednot requiring ASC reporting for2010. Still it would be wise to beready. Though CMS is postponingreporting for now, the agency saysin the proposed 2010 outpatientpayment rule, “It is our clear inten-

tion to implement quality report-ing in the future.”

The Collaboration “strongly ad-vocates quality reporting forASCs,” Slosburg says.

In its comment to CMS on theproposed rule, the Collaboration ex-pressed disappointment in theagency’s lack of progress and encour-aged CMS to move ahead quicklywith ASC quality reporting. �

The ASC Quality Collaboration data are at www.ascquality.org/qualityreport.html


not only because of lower pay-ments but because the cuts are com-ing at a time when volume is down.

“Like all types of businesses inthese economic times, we have al-ready seen ASCs working reducedhours and laying off staff. Therehave also been reports of ASCs clos-ing completely, doing joint ven-tures, or converting to HOPDs.”

Two specialties Serbin sees as es-pecially vulnerable are pain man-agement and GI procedures.

“In order to be profitable withsingle-specialty pain managementor GI endoscopy centers, the vol-ume must be exceptionally largeand the costs well contained,” shesays.

Medicare still rulesFor some surgery centers, it may

be tempting to withdraw fromMedicare altogether.

But Serbin does not expect thatto happen, especially in large multi-specialty ASCs, “because some spe-cialties are increasing in reimburse-ment.” Instead, centers are likely to

drop lower-paid procedures. Onemight be pain management, be-cause patients tend to be youngervictims of workplace or sports in-juries and not covered by Medicare.

On the other hand, Serbin notes,“a lot of private payers requireMedicare certification or accredita-tion, which also may requireMedicare certification, in order toparticipate in their networks.”

For facilities specializing in GIendoscopy, there is even greater in-centive to remain with Medicare be-cause the majority of their patientsare elderly.

A slightly different perspectivecomes from a study by KNG HealthConsulting, published in June 2009for the ASC Coalition, now part ofthe ASC Association. KNG foundbusiness shifting from hospitals tosurgery centers in the past decadedue to preferences of both physi-cians and patients. Ophthalmology,the largest-volume specialty forASCs, the researchers found, hashad the slowest growth since 2000.Meanwhile, the number of colono-scopies increased by 15% per yearduring that period.

At the same time, they note, the

Medicare population has remainedrelatively stable. Increases inMedicare spending for ASC ser-vices were almost entirely due toadditional services for current bene-ficiaries.

While the comment period forthe proposed rule has ended,Bryant advises ASCs to continuecommunicating with their legisla-tors in an effort to soften the impactof future cuts.

Pending legislationPending legislation is intended to

help. US Representatives KendrickMeek (D-FL) and Wally Herger (R-CA) have introduced the ASC AccessAct of 2009 (HR 2049). One provisionwould freeze ASC Medicare pay-ments at 50% of the HOPD rate,avoiding the downward trend thatwould otherwise continue in 2011.The bill was sent to the House Waysand Means Committee. The ASC As-sociation supports the measure, butspokeswoman Kay Tucker says law-makers are unlikely to take action be-fore the wider issue of health care re-form is resolved. �

—Paula DeJohn

Medicare payContinued from page 27


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P O Box 5303Santa Fe, NM 87502-5303


The monthly publication for OR decision makers Periodicals

At a Glance

Full moon, timing not linkedto CABG outcomes

There is no bad time or phase ofthe moon to have elective coronarybypass graft surgery, finds a newstudy.

Sleep deficits, body rhythm dis-turbances, and prolonged duty havebeen shown to reduce performanceof drivers and pilots. Researcherstested whether the same effectsmight occur with OR personnelwho work off-hours and long shifts.The researchers examined the phaseof the moon because of the beliefthat accidents and emergency de-partment visits increase at fullmoon.

They also looked at the month ofJuly when new residents start work-ing. None of the factors significantlyaffected outcomes.

—Tan P J, Xu M, Sessler D I, et al.Anesthesiology. 2009;111:785-789.

DuraPrep associated withlower SSI rate in study

In a study comparing effects of 3skin preparations on surgical site in-fection (SSI), an iodophor-based prepsolution (DuraPrep, 3M) was associ-ated with a lower infection rate thanchlorhexidine-isopropyl alcohol

(ChloraPrep, Cardinal Health). Nodifferences were seen between Dura-Prep and povidone-iodine (Beta-dine).

The 18-month study examined3,209 general surgery operationsperformed at one academic medicalcenter.

The main findings were some-what unexpected, said one of theauthors Robert G. Sawyer, MD.“Based on data derived from centralvenous catheter insertions, we hadthought the infection rates would belowest in the period where chlor-hexidine was the preferred agent forskin preparation. This was not thecase.” He added that the findingsneed to be reproduced in a multi-center study. The study was fundedby an unrestricted educational grantfrom 3M.

—Swenson B R, Hedrick T L, Metz-ger R, et al. Infect Control Hosp Epi-

demiol. 2009;30:964-971.

Companies in race for firstpercutaneous heart valve

Two companies are in a race toget Food and Drug Administrationapproval for the first percutaneousaortic valve, according to the Sep-tember 30 New York Times. Leadersare Edwards Lifesciences Corp and

Medtronic Inc. Edwards has a headstart, recently enrolling the last of1,000 patients in a major trial. TheEdwards valve could be on the USmarket in 2 years if the study is suc-cessful, and the device is approvedby the FDA. Medtronic entered therace in April when it purchasedCoreValve, a privately owned com-pany. Medtronic hopes to start a trialnext summer.

The new valves, available in Eu-rope for 18 months, sell for about$30,000. Presently, the valves areused in patients who are not candi-dates for conventional surgery.

—nytimes.com

Urologic surgeons call forrobotic surgery standards

The Society of Urologic RoboticSurgeons is calling for guidelinesand proctoring recommendationsfor robotic-assisted radical prostatec-tomy. Currently, there are no stan-dards for evaluating a surgeon’scompetency with the robot. Recom-mendations, published in the Sep-tember Journal of Urology, were to bediscussed at an international meet-ing in October. �

—Zom K C, Gautam G, Shalhav AL, et al. J Urol. 2009:182:828-829.

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